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A MANUAL 



OP 



OBSTETRICS. 



BY 

A. F. A. KING, A.M., M.D., 

Pn^taaor <:f ObeMricg and DUeoMa oS y^'o^fn and CltUdren in Die Medical Depart- 

maU t^ the Columbian VntveraUy, WashingUm, D.Ct ai*d in the Vnivcrsiiy oj 

VermmU: Prtaident {ias&~m-S7) of the Washington Ohetetrical and Gynx- 

cohffieal Society; Pretident il8ia) of tlie Medical Society uf D. C. ; 

ftilow of the BrUixfi Qyniecological and of the American tj'i/nsrco!ogical Societies ; 

Conndiing Physician to the Children's HotpHcd, ]\'u*hi»mttm, D, C. ; 

Ot>tteirician to the Columbian Vnivemity Hofpiial: 

Member 1^ the Wa^n^on Academy of Science$; of the Amedcan Attociation for 

the Advanamenl qf Science; Associate- Member of the PhUomphical Society 

t^ Great Britain; and Member (^ the Medical, Philosophical, AiUhro- 

pUoffieai, and Biological Societies of Washington, D.C., etc. 



EIGHTH EDITION, REVISED AND ENLARGED, 



WITH TWO HUNDRED AND SIXTY-FOUR ILLUSTRATIONS. 




LEA BROTHERS & CO. 

PHILADELPHIA AND NKW YORK 



Entered according to Act of Conin^ss, in the year 1900, by 

LEA BR0THERJ5 & CO., 

In the Office of the Librarian of Omgrcsfl, at Washingtun. All rights reserved. 



WE>»T('«»TT A TIIOMJhiS. 



DESIGNED IN rAUTlCT'LAR FOIt 



MY OWN STUDENTS, 



k MEDICAL CLASSES OF THE COLUMBIAN UNIVERSITY, 

t WASHINGTON, D. C, 

* AND THS 

* UNIVERSITY OF VERMONT, 

TO 



^TtffiE iSOQk 



IS AFFECTIONATELY DEDICATED, 

WITH TUB 

EARNEST HOPE THAT IT MAY BE OF SERVICE TO THEM, 
AND WITH THE BEST WISHES OF 

THE AUTHOR. 



53998 



PREFACE TO THE EIGHTH EDITION. 



It has not been necessary to add very much to this volume 
eonce the issue of the last edition two years ago. Some state- 
ments have, however, been modified in comformity with the 
progressive trend of obstetric thought ; several omissions have 
been supplied ; a few errors corrected ; and the text has been 
embellished with forty-one additional engravings. These last 
have been selected from the works of American authors whose 
names accompany the illustrations. 

Grateful for the favor with which former editions have beeu 
received, I hope that the present issue may not fail to deserve 
a continuance of the kindly approval bestowed upon its 
predecessors. 

The book still remains elementary : no attempt has been 
made to develop it into a systematic treatise. 

It gives me pleasure to thank the eminent publishers for 
the care with which they have managed the material pro- 
duction of the book, as well as for their efficiency in securing 
for the work an auspicious introduction abroad, by which its 
repute and sphere of usefulness have no doubt been largely 
extended. 

A. F. A. K. 
1315 Massachubetto Ave., N. W., 
Washington, I). C. 
Apbil, 1900. 



PBEFACE TO THE FIRST EDITION. 



The chief purpose of this book is to present, in an easily 
intelligible form, such an outline of the rudiments and essen- 
tials of Obstetric Science as may constitute a good ground- 
work for the student at the beginning of his obstetric studies, 
and one by which it is hoped he will be the better prepared 
to understand and assimilate the extensive knowledge and 
classical descriptions contained in larger and more elaborate 
textrbooks. Confessedly, in great part, a compilation from 
these, it is upon the more recent treatises of Leishman, Play- 
fair, and Lusk that I have most largely depended, as author- 
ities, in dealing with matters that are still unsettled, and it 
is with pleasure I acknowledge my indebtedness to these 
authors. 

Whatever value the book may possess as a book of refer- 
ence for the practitioner, I cannot but hope it may prove of 
service to those whose onerous duties allow but little leisure 
for consulting larger works, and who simply desire to refresh 
their minds upon the more essential points of obstetric 
practice. 

It will be observed I have attempted to anglicize the terms 
" ante-partum*' and ^'post-partHm*' into, respectively, **ante- 
partal" and ** post'partal." If this be considered an error, 
or an unwarrantable assum]>tion, I can only plead guilty, and 
await sentence from my confriires. 

vii 



Vlll 



PREFACE TO THE FIRST EDITION, 



For many of the illustrations — the plates of which were 
placed at my disposal hy the publishers — I am indebted to 
the works of Meigs, Leishman, and Playfair; for others, 
which will be found only in this work, my grateful acknowl- 
edgments are cordially extended to my friend and former 
pupil, Dr. William Nicholson, of this city. 

A. F. A. K. 

May, 1882. 



CONTENTS. 



CHAPTER I. 

IHTBODUCTION. THE PELVIS. 

The PeWis — Sacnun, Coccyx, and Innominate Bone — Planes and In- 
clined Planes — Sacro-sdatic Ligaments — Articulations of Pclvb— Tlie 
Parturient Canal — Canis's Curve — Mobility of Pelvic Joints— Meas- 
urements of the Pelvis — Diameters of the Straits and Cavity — Mus- 
cular Appendages of the Pelvis— The Pelvic Floor and Perineum. 

pp. 17 to 34 

CHAPTER II. 

THE FCETAL HEAD. 

Compressibility, Shape, Sutures, Fontanelles, Regions, Diameters, and 
Measurements. pp. 34 to 39 

CHAPTER III. 

KXTEBNAL GENERATIVE ORGANS. 

Mods Veneris, Labia Mtyora, Labia Minora, Fossa Navicularis, Clitoris, 
Vestibule, Urethra, Hymen, and Caruncuiie Myrtiformes. pp. 39 to 43 

CHAPTER IV. 

INTERNAL GENERATIVE ORGANS. 

Vagina, Utertis (its Structure, Ligaments, Arteries, Veins, Lymphatics, 
Mobility, Nerves, and Functions), Fallopian Tubes, and Ovaries — 
The Graafian Follicle and its Contents — Corpus Luteiim— The Paro- 
varium — Mammary Glands. pp. 43 to 65 

ix 



CONTENTS. 
CHAPTER V. 

MENHTRCATION AKD OVUI.A'nOK. 

Cause, Symptoms, uid accompanying Cliuiges in Uterine Mucous Mem* 
bnuie — hestiny of the Ovule— Signs of Puberty —Quantity :md S*nirce 
of Menslmal Fluw — Vioariuuii Meustruatiua — Periodicity and Nor- 
mal Suit|ienHKHi of MenwH. pp. 65 to 70 

CHAPTER VI. 

MATIHATION, FECUNDATIOS, ANII NTTTniTION OF THE 0\*UM. 

The Bi»ermntic Kluiil— Changes in Ovule after Imprci^iation — Blasto- 
(tertnio Membranes — Vitelline Memhnme — Amniftn — Allantoii* — 
Chorion— The l>ecidua Vera, Reflexa, and Scrotina— Placenta — 
Umbilical Cord — Nutrition of Fcetus — FtPtal Circulation: Changen 
in CircuUlion after Birth. pp. 70 to lOl 



CHAPTER VII. 

THB fitnNB OF puxxaxANcy. 

Citaufication — Early Diagnosis of Pn'ffnuncy — Pcwitice Sijms : The 
Fcrtal Heart t^imdn, Quickenint?, Balhttlement. I'terine Murmur and 
Intermittent Uterine Conlraolious, Ht^rar's Sign — I>iiubtrul Signs: 
Rupprei-tsion of Menkes, Rrea»t Sipns, Morning Sickness, l^Iorbid 
l^nifpngft, Changea in Abdomen, Softening anil Enlai^Mnenl of Og 
and Cervix Uteri, Violet t'olor of Vagina, Kieslein, Pigmentary 
Depoiit in Skin, Mental and Emotional Signs — Monthly Succeasion 
of Sign** — Differeiilinl Di;igQOHi9 of I'regnancy — Order of Examina- 
tion iu Suspected Pregnancy. pp. 101 to 128 



I 



CHAPTER VIII. 

HTOIENE AXD TATnOLOOV OF rUKJNANCY. 

Hygiene and Management of Normal Pregnancy: Air, Dre*w, Exercise 
and Travel, FtM^Kl, the Skin. Sleep, Sexual Alisliuence — Diiteases of 
Pregnancy — Clajwificution— Salivalitm — T(M>thathe and Dental Caries 
— Exeeatfive Vomiting — CouHtipation — Piarrhcea — Albuminuria — 
Diabetes— Bright' 8 DL<*caM^ — Unpmia — Convulsions — Irritable Blad- 
der — Incontinence of Urine — Uterine Displaccmentii — Ijcuoorrhtea — 



CONTENTS. XX 

Pruritoa Vulyae — Painful Mamnue — Palpitation — Syncope — Varicose 
Veins — Anaemia and Plethora — Cough and D^i^noea — Nervous Dis- 
: Chorea, Sciatica, General Pruritus, etc pp. 129 to 162 



CHAPTER IX. 

INTEBCtJBRENT DISEASES OP PREGNANCY. 

Aoddaitai Coincidences — Intermittent Fever, or Ague — Relapsing 
Fever or Famine Fever — Typhoid and Typhus Fevers — Yellow 
Fever— Scarlet Fever—Measles (Rubeola) — Smallpox (Variola) and 
Varioloid — Cholera — Pneumonia — Phthisis — Heart Disease — Jaun- 
dice and Acute Yellow Atrophy of the Liver. pp. 162 to 169 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Definition, Frequency, Causes, Period, Symptoms, Prognosis, Diagno- 
sis, and Treatment — "Injperfect" Abortion — "Missed" Abortion. 

pp. 169 to 180 

CHAPTER XI. 

EXTRA-UTERINE PREGNANXY. 

Varieties — ^Tubal Pregnancy: its Causes, Symptoms, Diagnosis, and 
Treatment — Ovarian and Interstitial Varieties — Abdominal Preg- 
nancy: its Diagnosis and Treatment — Hydatidiform Pr^ynancy — 
Moles: True and False — Polyhydramnios — Oligohydramnios — Hy- 
drorrhoea. pp. 180 to 201 

CHAPTER XII. 

LABOR. 

Mode of Foretelling Date of— Causes and Forces of^ Labor-pains — 
The "Bag of Waters" — Stages of Labor — Symptoms— Phenomena 
of the Several Stages — Duration and Management of Labor — Prep- 
aration for Emergencies — Antiseptic Midwifery and Antiseptics — 
Examination of Female: Verbal, Abdominal, and Vaginal — Purposes 
of Latter — Arrangements of Bed and Night-dress — Rupture of Bag 
of Waters — Attendants — Pinching of Os Uteri against Pubes — Atten- 
tion to Perineum — Birth of Head— Tying the Cord — Delivery of 



CONTENTS. 

Plftconta— The Biiuler— "OccIuKion T>r««ng'* 
bum Child — Dmsbiiig' Sluuip uf Xavel String. 



■Attentions to Xew- 
lip. 201 tu 239 



CHAPTKK XIII. 

MANAOEMEHT OP MOTlfEB AVD CIIILU AKTER PRLITEBT. 

General Condition of Lying-in Woman — The Lochial Discharge — 
AftiTiwins— Snoklinj^ the L-hild — The Infant's Boweltt and urine — 
The MothcKtt ]ir>wt'lri and Urine — Her I>iet — Milk Fever — Sore 
Nipples— Sunken Nipples— KxcchS uf Milk— Deficient Milk — Arti- 
firial Fcetlint; — Infnntilo Jaimdiee— Sure Navel — Unihiltoil Hernia 
— Sot-yndary HemnrrhasTi' frim Navel — InHmned Breasti* of Iiifaul — 
Time of (jetting Up after Delivery — (Ophthalmia Neonnumim. 

pp. 239 to 251 

CHAPTER XIV. 

MECHANISM OF LABOR IN IIEAlJ rRKSENTATlONS. 

Posture of Child in Utcnw— Kour " Pfwllimw" of Head "Preeenta- 
limi" — Meehniiisiii in Ix-ft Occipito-anlerior Position— Flexion — 
Deaeent — Kotation — Kxtension — Ke*.titnti(>n — MechaniHin nf Other 
Ptwilion-s — Dia^icniisis of Posilion— Prngnoaia and Treatment in Oc- 
eip)to*ai)terior PntiitionA, and in Occipilo-posterior ones. 

pp, 251 to 267 

CHAPTER XV. 

FACE PUEKEMTATIOMS. 

CauBes, Frequency, and Ptwititms nf— McchanUra m Mento-anterior 
PoMitioiis: Kxten.sion, DwH-ent, Itotatiun, Flexion, and Ki*Hti[ution — 
Me«-haniiMn in Monti>pos(crior Positions -Cause uf Arn'sl after Pos- 
terior Kotation of Chin — Diagnosis, PrognoeiH, ami Treatment of 
F:ice fuse* — Conversion of Face into Head Presentalion by Kxtemal 
Manipulation — Brow PrcsentalionH. pp. 267 to 280 



CHAPTER XVI. 

BREECH, KNEE, AND FOOT PHESEKTATIOKS, 

Positions of— Meehuni*m in Sacni- anterior Pwitions -Mechanism in 
Haoro*posterii>r PneilioiM- Knee and Footling Prtseulationa — Diag- 



€X>NTENTlSi xiii 

noeis of Breecli, Knee, and Foot — Prognous and Treatment of Breecli 
Caseis — Delivery of After-coming Head — Difficulty in Breech Cases — 
Forceps applied to Breech. pp. 280 to 304 

CHAPTER XVU. 

TKANBYJERSE PBESENTATIOITS. 

Poflition and Mechanism of— Spontaneous Version — Spontaneous Evo- 
lution — Causes and Diagnoeis of Transverse Cases — Diagnosis of 
Shoulder and Elbow, and of One Shoulder from the Other — Prog* 
noais and Treatment pp. 304 to 313 

CHAPTER XVIII. 

OPEBATITE MIDWIFERY. INSTRUMENTS. 

The Fillet, Blunt-hook, Vectis, and Forceps — Long and Short Forceps 
— Action of Forceps — Cases in which they are Used— The '*Higli" 
and "Low" Operations — C<niditions Essential to Safety — Application 
of Forceps at Inferior Strait after Anterior Rotation of Occiput — 
Oscillatory Movement — Application at Inferior Strait after Posterior 
Rotation — Application before Rotation — Application in Pelvic Cavity 
— The "High" Operation — Tamier's, Lusk's, and Simpson's Axis- 
traction Forceps — Dangers of Forceps Operations— Forcof» in Face 

• Presentations — Forceps to the After-coming Head in Breech Cases. 

pp. 314 to 341 

CHAPTER XIX. 

TKRSION OR TURNING. 

Cephalic and Podalic — Methods of Operating: by External, Bipolar, 
and Internal Manipulation — Version in Head Presentation— Version 
in Transverse Presentations— Where to Find the Feet — Prola|>se of 
the Arm — Difficulties of Version. pp. 341 to 358 

CHAITER XX. 

CUTTINO OPERATIONS ON THE MOTHER. 

Symphyseotomy: Closed Method, Oi»en Method — Aycr's Operation— 
CcsaRAn Section : Prognosis and Dangers of, Method of Oiierating, 



XIV 



COSTESTS, 



Frilsch's Kundul Incision — After-treatment — I^aparutoniy — Laparo- 
clytrotoniy — I'urro's Oporution— The Piimi-MulU'r Operalion. 

pp. 358 to 380 

CHAPTER XXr. 

MCTtLATiyO OPERATIOXS VTOV TBC CHILD. 

Cranioloniy— Embryotomy— PerfonitorH — Smcllie's Sciaswrs — Perforn- 
lion — Excerehralion — CephalolrijJBy — The Cranioclast — Braun's 
Cnuiioclii5l — <-'«phalutribc —^Craniotomy Forrejw — * rolrliet — liasiiv 
Iripsy— Baaiotribe — liiisilysl — Evisceration — Dt'fapitalion, 

PI). 380 to 396 

CHAPTER XXII. 

PELVIC DEFORMTTIB?. 

Syratnetrically Enlarged Pelvis— Symmelrioilly Contracted Pelvis — 
The Juvenile Pelvis— The Mitsenline Pelvis — The Pelvis of Kickelit 
— The Maluootiteou Pelvis — Oblique Deformity of Naejrel^ — The 
" RobcrtA Pelviti " — The Spotidylolislhelic I'elvia — The Kyphotic 
Pclvifl— Deformity from ]iip Dit*easc, Exostosis, etc — Symptoms of 
Deformity — Pelvimetry: Internal and Extonial — Diagnosis of Vari- 
eties — Danger* of Deformed Pelves — ModiHc:ttion8 in Mechaniuu of 
Labor — Mclhodn of A«i»tin(^ Delivery in Pelvic Deformity. 

pp. 396 to 425 

CHAITER XXIII. 

UffDUCTION OP PREMATDTIE LABOR. 

proper for— Objects of \in Emph^ymcnt in Pelvic Deformity — 
[ethodn of Inducing Labor before (liild is Viable — I^cst Method 
when Child i« Viable — Other Methods: the Vaginal I>oiiche, Cohen's 
Method, Vaginal Tampon, Sponp(stenl, Injections of Sterilized Glyc- 
erine, Ergot, etc — Treatment "f Prematnre Infanti). pp. 425 to 436 

CHAPTER XXIV. 

PLACENTA PREVIA. 



Hemorrhage before Delivery — Cattfies, Consequences, Symptoms, Diag- 
noei», and PrognoHis of F'laeenla Pnevia — Treatment : before and after 
Viability of Child — Delivery— Version or Forceps — Tampon — Dili- 



CONTENTS, XV 

tore — Kigot — Buptura of Membranes — Barneys Partial Digital Sepa- 
ration of Placenta — Cohen and Davis* Method— Simpson's Method 
— Treatment after Delivery — Hemorrhage before Labor without 
Placenta Pztevia : Its STmptomSf Prognosis, and Treatment. 

pp. 437 to 444 

CHAPTER XXV. 

POart-PAKTAL HEMOBBHAGE. 

"Flooding" — Its Causes, Prevention, Symptoms, and Treatment — Pre- 
ventive Measures — Remedies to Arrest Flow— Removal of Placenta 
and Blood Clots — Manipulation of Uterus— Lemon-juice, Vinegar, 
Ice, Hot Water, and Styptic Iron Applied to the Uterine Cavity- 
Compression of Aorta — No Tampon — Iodoform Gauze — Remedies for 
Syncope — Retidned Placenta — Hour-glass Contraction of Uterus — 
Spasm of the Os— Treatment of Large Placenta. pp. 444 to 466 

CHAPTER XXVI. 

INVEESION OP THE UTEBU3. 

Varieties (or D^^rees), Causes, Symptoms, Pr<^06is, Danger, Diagnosis 
from Polypus, and Treatment pp. 457 to 460 

CHAPTER XXVn. 

RUPTURE OP UTEBU3. 

Causes, Symptoms, Pn^nosis, and Treatment — Laceration of Cervix 
Uteri — Laceration of Vagina and Vulva — Thrombus of Vulva — 
Rupture of Perineum— Loosening of Pelvic Articulations. 

pp. 460 to 472 

CHAPTER XXVIIL 

MULTIPLE PREGNANCY, ETC. 

Twin, Triplet, Quadruplet, and Qnintuplet Births — Arrangement of 
Placentse in Twins — Diagnosis and Prt^osis of Plural Pregnancy — 
Treatment of Twin Labors — Treatment of " Ix)cked Twins" — Hydro- 
cephalus: Its Diagnosis, Prognosia, and Treatment — Encephalocele — 
Ascites, Tympanites — Distention of Bladder — Large Size of Child — 
Premature Oasification of Cranium. pp. 472 to 483 



xvi CONTENTS, 

CHAPTER XXIX. 

TEDIOUS I.ABOB. 

CauHes, PrognoeiBf Symptoms, Diagnoeis, and Treatment — Swelling of 
Anterior Lip of Uterua — Rigid Ob Uteri — Rigidity of Perineam — 
Mode of Delivery in Tedious Labor — Powerless Labor— Precipitate 
Labor: Its Causes, Symptoms, and Treatment pp. 483 to 491 

CHAPTER XXX. 

DIFFICULT LABOR. 

Obrtniction by Maternal Soft Parts — Imperforate Hymen — Atresia and 
QCdema of Vulva — Atresia of Vagina — Cystocele — Rectooele — Im- 
pacted Fec« — Vesical Calculus — Vaginismus — Growths in Vaginal 
AValls— Hernia— Occluhion of Os Uteri — Atresia of Cervix Uteri — 
Cancer of Cervix — Ante-partal Hour-glass Contraction of Uterine 
Body — Polypus — Fibroid and Ovarian Tumors — Hernia of Gravid 
Uterus. pp. 492 to 506 

CHAPTER XXXL 

PROTJIFSE OF FUNIS. 

Causes, Prognosis, Diagnosis, and Treatment — Postural Treatment — 
licpofii tors— Short and Coiled Funis: Symptoms and Treatment — 
Knots in the Cord. pp. 505 to 515 

CHAl^TER XXXn. 

AN.«»THEnC8 IN MIDWIFERY. 

General I'se of — Chloroform — Sulphuric Ether — Hydrate of Cliloral, 
Use of, in I^bor, Eclami^io, Mania, etc. — Ergot : Dan^rs and Ccm- 
tra-indications to Use of — Quinia as an Oxytocic. pp. 615 to 5^ 

CHAI^ER XXXIII. 

PtIKRPERAL F-OLAMPSIA Dt'RINO LABOR. 

Symptoms and Clinical History — Varieties— Prognosis and Treatment. 

pp. 520 to 524 



CONTENTS, xvii 

CHAPTER XXXIV. 

PUERPERAL SEPTJCJi^MIA. 

Definition and Synonyms— Channels of Infection — Causes and Origin — 
M tcrubes — Bacteria and Streptococci, Sources of — Sy mptora« and 
I*iUhology — Itlood-|K)isoning and Local Inllanimutions — ** Acutost 
tseptica'niia" — Vulvitis, Vaginitis, Metritis, Salpingitis, Ovaritis, 
Cellulitis, Pelvic Peritonitis, Abdominal Peritonitis, Pericarditis, 
Pleuritis, Plilebitis, Lymphangitis — ProgntMiis — Treatment: Preven- 
tive, Curative, Antisepsis, General Support — Treatment of Various 
Local Inflammations— Use of ^^uclein, Ilypodermoclysis of Norma! 
Salt Solution, Antistreptococcic Serum— Concluding Remarks. 

pp. 524 to 550 

CHAPTER XXXV. 

CENTRAL VENOUS THROMBOSIS (IIEARTCLOT). 

Causes — Poat-mortem Ap[>earanccs — Symptoms, Prognosis, Diagnosis, 
and Treatment — Peripheral Venous ThntmlM>sis (" Milk Leg " ), 
"Phl^^iasia Oolens:" Causes and Pathology, Symptoms, ProgiHMiis, 
Local and General Treatment — Arterial Thrombosis and Embolism : 
Symptoms and Treatment. pp. 550 to 556 



CHAPTER XXXVI. 

INSANITY llURINO GESTATION, LACTATION, AND THE PUERPERAL 

STATE. 

Insanity of Ocslation, Lactation, and tlie Pucriwral State- Causes — 
Svmptoms of each Variety — Pr(»gnf»sis as to Life and Mcnl:d Kcsto- 
ration — Treatment — I'uerperal Tetanus — Tetanoid Contraitions. 

pp. 55G to 501 

CHAPTER XXXVIL 

INFLAMMATION OK IIUKASTS. 

Varieties— Causes — Symptoms — Treatment — Lactation and Weaning — 
Wet-nurses. pp. 561 to 567 



xviu CONTENTS, 

CIIAPTEK XXXVIII. 

RI-SUHCITATION OF ASP«Y.\iATKl> CHILDREN. 

Asphyxia Neonatonim— Canscs — Symptoms — Varieties : livid and 
i'allid — Projunosis — Treat men t^Kemoval of Foreign Matters from 
Air-pas8ag«4 — Uae of Catheter in Tracliea — (iet Air into Luufj^s — 
Schultze's Mctliod — Sylvester's Method— Laborde'a Method— Byrd- 
Dew Method — Bniat's Method. pp. 667 to 574 

CHA1>TER XXXIX. 

OIISTETKIC JlTUISPRtrnENCE. 

Unusual Prolongation of Pregnancy — Age of Maternity — Short Pr^- 
nancies with Living Children — Api>ejirunee of Fa'tus at Different 
Periods of Ciestation — Susi>ected Conjugal Infidelity — Moles — Diag- 
nosis of Pregnancy — Signs <if Recent Abortion — Signs of Kecent 
Delivery at Terra — Unconscious Delivery— Feigned Delivery — Crim- 
inal Abortion — Medicinal Oxytocics — Mode of Examination after 
Instrumental Methods— Infanticide— Tnspwtion of Chihrs Body — 
Duration of 8urviv:d after Hirtli — Kvidence of Live Birth — Static 
Test — Hydnwtatic Test— Value of Kespiration as Kvidence of Live 
Birth — Evi<lence from Circulatory Organs and Stomach — Xatural 
Causes of Death in XewlK)ni Children — Violent Caus<'S, Accidental 
and Criminal — Strangulation- Medical Kvidence of Raite — Marks of 
Violence on Genitals and Bmly — Examination of Clothing— Venereal 
Discuses — Signs of Virginity — Pregnancy resulting from Rape — 
Imiwtcnce. pp. 575 to 59G 



Appendix. Olwtetrical Nomenclature. 597 



LIST OF ILLUSTRATIONS. 



no. PAGE 

1. Pelvis: Superior strait and its diameters 18 

2. Pelvis: Inferior strait and its diameters 23 

3. Axis of parturient canal 26 

4. Conjugate diameter of su(>erior strait 29 

5. Fontaiielles 36 

6. Fu'tal head and its diameters 38 

7. Generative orjg^ans — internal and external 45 

8. Section of uterus before pregnancy 47 

9. Section of uterus after childbirth 47 

10. Internal generative organs 49 

11. Internal generative oi^ans seen from above 50 

12. Blood-supply of uterus 51 

13. Ix)ngitudinal section of Fallopian tube 54 

14. Relations of ovary with uterus and Fallopian tube 55 

15. Graafian follicle and ita contents (diagrammatic) 56 

16. Section of ovary of human Pit'tus with developing ovules ... 68 

17. Section of mammalian ovary showing germinal epitlielium ... 59 

18. Corpus luteum of menstruation, third week 60 

19. Cori»ns luteum of pregnancy, fourth month 61 

20. Corpus lutenm of pregnancy at term 61 

21. Parovarium, ovary, and Fallopian tnl)0 62 

22. Globulin of healthy milk 63 

23. Cialactophorous ducts 04 

24. Colostrum and ordinary milk globules 65 

25. Segmentation of the ovule 7.3 

26. Formation of cpibla.st and hypoblast 74 

27. I'^onnalion of hiastoflermic vesicle 75 

28. Mammalian blastodermic vesicle 76 

29. Medullary foidn and groove 78 

30. Medullary canal, etc 78 

xix 



XX LIST OF ILLUSTRATIONS. 

FlU. PAOB 

31. Neural canal further developed 79 

32. C'ross-seetion of oinbryo in dorsal r^ion 79 

33. Forniati<m of ''side-folds" or atxlominal plates 80 

34. Cross-section showing "side-folds," etc. 81 

35. IjOngitudinal section— alxloniinal cavity, etc 81 

30. Conversion of medullary groove into the neural canal .... 83 

37. Amnion : its Ix^inning 84 

38. Ik'ginning of allantois 85 

39. Meeting of amniotic folds — further development of allantois . 86 

40. Allantois and chorion 87 

41. 42. Formation of amniotic cavity 88 

43, 44. Formation of alimentary canal, etc. 89 

45. Dccidua vera 90 

46. Decidua reflcxa and serotina 90 

47. The same, further developed 91 

48. Front view of Keichert's embryo 92 

49. Side view of Kciclicrt's embryo 92 

60. Diagranmiatic section of same 92 

61. Ilis's ovmn 93 

52. Human ovum during third week 93 

53. Human ovum witli cotttained embryo, al)out the end of third 

week (natural size) 94 

54. Human foetus, five weeks old 94 

55. Diagnwnmatic section of jdacental Ktrncture 96 

56. Placenta — uterine surface 97 

57. Placenta — fo'tal surface. . 98 

5S. Kxamination for (juickening 106 

59. Kxaminatiou by ballottemcnt 107 

60. Hcgar's sign — chant^e of shape 110 

61. Sliape of nun-prognant uterus 110 

62. Shapo of uterus in early pregnancy 110 

63. iV'nmnstrnlion of Hegar'ssign Ill 

64. The same with fundus uteri forward 112 

65. Ilftrar's sign by recto-vaginal examinati<m 113 

66. Size of uterus at varinns periods of preg!iancy 119 

67. I >cnioii.straling enlarged utenis by palpation of abdomen . . . 120 

6H. Retroversion of gravi<l nteriLs at twelfth week 161 

60. Kotro-r/rr/ftn of gravid utcnis — sixteenth week 152 

70. liisacculated gravid uterus 163 

71. Pregnancy in extenial third of left tube 181 



LIST OP ILLUSTRATIONS. xxi 

18. PAGE 

72. Pregnancy in right tube, partialiy ir.tra-Iigamentous .... 183 

73. Interstitial or tnbo-ovarian pregnancy 188 

74. Ovarian pregnancy, left side 189 

75. Uterus and foetus in abdominal pregnancy 190 

76. Lithopeedion li»2 

77. llydutidifomi d^eneration of churiul villi 194 

78. Double sac explaining liydrorrhaa 200 

79. Diagram for determining date uf lalK>r 201 

80. Digital diagnosis of commencing dilutiition of the os uteri . . 200 

81. Os uteri farther dilated 20(> 

82. C<Hnplete dilatation of the oe uteri 207 

83. Head at vulval opening distending i>erinenm 208 

84. Head about to pat« the vulval opening 209 

85. Flexion causing occiput to descend and forclioad to rhe . . . 217 

86. Palpating head in lower part of uterus alnivc pelvic brim . . 218 

87. Palpating the breech 219 

88. PaljMiting plane of biu'k and movable small parts 220 

89. Palpating hard globtilar head with one hand 221 

90. Palpation : head in pelvic cavity 22.'J 

91. Mode of efTecting relaxation of perineum 2IH) 

92. Kellogg' s elastic funis-ring applicator 2Ho 

93. Kxpression of the placenta (Oed^) 2.J4 

94. Faulty method of extracting placenta 235 

95. Normal doubling of placenta 230 

96-101. Six "ixwitions" of head (vertex) "jirescntation" . • - 252 

102. Influence of flexi<m in pcmiilting descent 250 

103. Occiput at inferior strait after anterit)r rotatinn 258 

104. Upward extension of occiput 259 

105. RestituticMi — external rotation 2G0 

106. Successive stages of mechanism in (Hripito-antcrior position 

of head prcsent:ition 201 

107. Extension after pofterior rotation 2fi2 

108. Successive stages of imH-'hanisni In occipito-pitstcrior position . 204 
109-114. Six "positions" of face "prcscnlation" 2fi*» 

115. Transverse (Kwition of face at superior stniit 270 

116. Influence of extension in pcrmittinir descent 272 

117. Anterior rotation of chin 2/2 

118. Delivery by npward llcxinn of cliin 272 

119. Successive stages in mciito jHisterior positlim of face, with 

ajUerior rotation 274 



zzu 



LIST OF ILLUSTRATIONS. 




rta. rAda 

120. Arrest of rocchnniiim lUWr fHWtcrior roUliun of chin .... 275 

121. Cluinif^ing fitcA Ut vertex Uy external nmrii|Hilati()n 270 

122-127. SU *'|)otfilion»" of brwch **pn.^sfnUiium" 281 

128. Breet'h presentation — le^ extended . 2K2 

129. lt«talion and dclivtTv of hips 284 

I'W). Koti^ticm of •Uiouldent . 'ISo 

131. Dcllvcrv of lower fthonhlor first at the perineum ...... 28$ 

IM'i, Anteriiir rotation of wcipnt of aflor-c<in>ing lie*! 28(5 

133. Piwtorior rot.ilioii of iKiipnl and deliver.* hv flexion .... 288 

134. i'oMterior rotiilion of iKT.ipiit :ind delivery hy cxtenxiun . . . 289 

135. I>iuj^)cwiji of |H>lvic prcMenUition liy {nipatinu '2\H 

136. Extraetiun of hcJid In breeoh etudes -95 

137. Kxlriiction of iifter-(»miiig head 295 

13ft. Tmctiiiii when jiflf-r-rominc hem! is arrested at saperiorfftnut . 297 

13D. Trnclion witli handkerchief when after-eouiiug hvad is arrested 

KiK'h up 298 

140. TnmierV foroejw applied to thiiifhs 299 

141. I'titf of fillet when lejpi nrc cxioodod 300 

142. MethotI of liringing dnwn f.x>t wlicn le;f8 are extended. . . . 301 

243. Blunt hoiik npplied lo iho breeeh . 303 

144, 143. Twu ptisitions of ri[;iit i^honldcr presentation 305 

146, 147. Two [HMitiofiB of left HboiiltU'r presentation 305 

148. Chinra'if frozen 8cctimi showing arrested ttpontaneniis evolu- 

tion 307 

149. Ppontane'ins evolution — first stnj^c 308 

150. Spontnneons evuhitiiin— second MtKge 309 

151. SpontiinetiU'* evolution— third ftaire , 310 

162. Uiugitoiiii^ of 8)iotjlder pruticnltitlon by palpmtion 311 

163. The bhmt-ho(»k .' 315 

154. The vetlia 316 

165. Den nuin'H abort foreeiM 316 

15G. Ho<lfri>'j| loniL; fortv^M 317 

157. Simiiftin's I0115 fon-ejis 317 

158. Use of fonx'iw ol nutlet— ininKluction of fir«t blade 320 

150. Inlroduolion of MH-ond blade 321 

IflO. I.iflini; hundles to lnll*»w extension 322 

I'll, hitn^bicin^r lower blnde of foroepa, patient on left side . . . 323 

162. IntriHliirincf np|ier bl/ule, in »ame pudition of patient .... 323 

1(]3. Foreeiw in position, .\xis-traction. Patient on left itide , . 324 

1S4. Last stage — extraction of head, woman on lefl eide 325 



J 



LIST OP ILLUSTRATIONS. xxiii 

no. rAos 

165. Forceps applied at inferior strait— occiput to left acetabulum . 328 

l(i6. Lusk's modification of Taraier's forceps 330 

167. Simpson's axis-traction forceps 331 

168. Walcher^s position 332 

169. Diagram showing lengthening of conjugate by Watcher's 

position 332 

170. McFarran's axis-traction forceps 333 

171. Breue's axis-traction forceiM 334 

172. Stephen»on*s metliod of axis-traction 335 

173. Traction with Simpson's forceps 336 

174. Traction with axis traction forceps 337 

175. Axis-traction with ordinary forceps — liead at superior strait . 338 

176. Forceps in face presentation at outlet 339 

177. Forceps to after-coming head at inferior strait— occiput at 

pubea 340 

178. Bipolar version — first step 344 

179. Bi)H)lar version — second step ' . . 345 

180. Bi[K>Iar version — tliird step 346 

181. Podalic version — grasping the feet 348 

182. Podalic version — turning the child 349 

183. Delivery of posterior arm when extended 355 

184. Delivery of anterior arm when extended 356 

185,186. Dorsal displacement of the arm , . 357 

187. Galbiati's knife for p^-mphyseotomy 3f)2 

188. Suturing uterine incision in Ceraareau section 372 

189. The same sutures when tied 373 

190. 191, 192. Various forms of perforators 381 

193. Perforation of the skull 382 

194. Martin's trephine 383 

195. Perforation with Martin's trephine 384 

196. Tamier's perforator 385 

197. The cephalotribe 386 

19S. A smaller craniocIoHt 387 

199. Braun'scnmioclast with screw 887 

200, 201. Craniotomy forceps 3H9 

202. Straight craniotomy forceiw 390 

203. (Xirvcd craniotoniy forceps 390 

204. 205. Crochets 390 

206. Simpson's basilyst 391 

207. Simpson's basilyst when applied 391 



xxiv LIST OF rLLUSTHATIONS. 

no. pAgc 

208. Tamier'8 basiotribe . 392 

209. Application of Tarnier's basiotribe 393 

210. Baaiotripsy accomplished 393 

211. Decapitation 395 

212. Justo-major and justo-minor pelvis 397 

213. Infantile or juvenile pelvis 398 

214. Flat rachitic pelvis 399 

215. Rachitic pelvis with depression of pubes 400 

216. 217. Osteomalacic pelves 403 

218. Obliqne deformity of NaegeM 404 

219. The Roberts' pelvis 405 

220. Spondylolisthetic pelvis 405 

221. The kyphotic pelvis 406 

222. Deformity from hip disease 407 

223. Bony tumor of sacrum . 408 

224. Greenhalgh's pelvimeter 409 

226. Baudelowiue's calipers and Coutouly's pelvimeter applied . . 410 

226. CoUyer'fi pelvimeter 411 

227. Pelvimetry witli the finger 412 

228. Measuring diagonal conjugate with two fingers 413 

2!!9. Measuring diagonal conjugate with whole hand 414 

230. Lumley Karle's jielvimeter 414 

231. Head passing inlet of fiat i>elvis 417 

232. Extreme flexion in generally contracted pelvis 418 

233. Relative scale of inches and centimeters 421 

234. Narrow hu^e of fa*(al head 423 

235. Further narrowing by pressure after turning 423 

236. Barnes's dilator — water bag 430 

237. Dilator of Champetier de Ribes and forceps for introtlucing 

it 431 

238. A 8im]>le incubator 435 

239. Tul)e and ftinnol for gavage 430 

240. Itimanual compression, producing antefiexion, to arrest flood- 

ing 448 

241. Hour-gla.s3 contraction of the uterus 455 

242. Inversion of the uterus 457 

243. Inversion beginning at the cervix 458 

244. ImiK>nding uterine rupture in arm presentation 461 

245. Im|)cnding rupture in hydmcephalus 462 

246. Lockeil twins, both heads ]>resenting 476 



LIST OF ILLUSTRATIONS, 



XXV 



no. PACK 

247. Locked twins, one breech, one head 477 

248. Hydrocephalus impeding labor 479 

24U. Knccphalocele 480 

250. Distaition of child's bladder obstructing labor 482 

251. Elongated cervix with procidentia during labor 493 

252. Cystocele obstructing labor 498 

253. Polypus obstructing labor 502 

254. Ovarian tumor obstructing labor 503 

255. Prolapse of cord by side of head 506 

256. Postural treatment of prolapsed cord 608 

257. 258. Reposition of prolapsed cord 510 

259, 260, 261. Other methods of re|>ositing cord 6U 

262. Hand prolapsed by side of head 513 

263. Schultze's method of artificial respiration — position of inspira- 

tion 571 

264. Schultze's method of artificial respiration— position of expira- 

tion 571 



OBSTETRICS 



CUAPTEll I. 



INTRODPCrrON. — THE PELVIS. 



'BSTETRirs is the wience and art of midwifery. Its ohje<-l 
IS " Ihe maini^ement of wonmii ami hor oHJjpriug <luring |>reg- 
iianov, lalM»r, and the puerjieral state." In itj* wider (kO|*e it 
eiuhraffs a knowledge of the structure aud fiinctioiiH of the r^ 
productive urgnns aud of their relationn CO the general system. 

The Pelvis. — The word "pelvis" means hasiu. It i« a 
strong framework of l)oue», in which the reproductive organs 
are containfMl and to which they are attached, and ilfi cavity 
coiilri1}ut4S to fonii a canal through which the child uiust pats 
_during parturition. 

It is coni[K>8<Hl of the right and left iiiuomiuate bones, 
•ura, and coccyx. 

The Sacritm and Coccyx.— The following anatomical 
features of the sacrum are of ohc^tetric^il im[)ortance: 

FirM^ its prottwntorif — the central, jmyecting, anterior border 
of the 8ui)erior surface (or haj»e) of the heme. From this prorn- 
(mtoHr' the anterv>-i>ot*terior diameter of the Ifrim of the pelvic 
Afw/» ii4 meOitured, and a nmteriMl re<iuction in its distance 
from the symphysis puhis, dire<*tly f>p|»osite, •'t^Dmitute.s the 
monf common variety of [»elvic defornjity. The Hinootk cotir 
vexxty of the anterior In^rder of the pnjmoolory i» imftortaut^ 
for it causes the globular head of the child to glide off. <iuring 
labor, to one or other side of Ihe nie4lian line, where there is 
more room for it to pass as will l>e explaine<i hereafter. 

SeajmL The anterior cutuyive ifurface or "/lo/A/if" of tlie 
1 17 



18 



lyTnoDUCTlON.—TIff^ PELVIS. 



fiacrum. It i-ontrihutcw to jrive ampliliide and ourvature to 
tlie pelvic caual. It 18 in confoniiity with thin rtmature of 
the wirnim that the loiip obHtetriral fon-ejxs is made with what 
in calUnl it« *' sjK'ral curve." Malt^ria! increajie or decr«n^t^ in 
the (]e;;;ree of wkthI curvature cotistitutw deformity, and may 
render hilnir mechanically <lifticult or im|x>s#ibk'. Karely 
lioiiy tumors (exiistiLst-i) spriiijf from the anterior surface of 
the fiarrum and ohstrurt delivery. Thi:^ surface of llie Imjuo 
itf pierced l>y the nnterior iiacral foramina, which give exit to 
the anterior nacral nerves. 

Third. Each htterni ifurfncet}( the Bacrum presents a rough, 
ear-sha|>ed area — the aurirular^ aHicuhir imrftice — covered with 




!. Ant«ro-pos1crlor (coaJ^Katuj. z bih-iliiic (tmmviTse). 3. OWIiine. 

onrtilape» which jniuff a mmilar shaped surface on the iliac 

Ijoue, coiislitutinp: the mero-iliar Mt/ttchondntinii. The |>oHte- 
rior ends of the nhliqnt' tUmnfitrn of the |»elvic hnni terminate 
at the sacro-iliac synchondmses'. That |Mirtion of tlu* bone 
extending from the sacro-iliac synchondrosis to the ^*ide of the 
IkhIv of the Hrst wicral vertebra i» called the u^ivif (ula) of the 
sacrum ; one i»n each nide, of oiurtie. (See Fi^'. 1.) 

Fourth. The a|»ex, or inferior extremiiy of the sacrum, 
presents a tran»ven!*Iy oval fwcet, covere<l with cartilage, for 
articulation with a correRjMHidin^ oval surface upon the tvMvyx. 
The pacnwKTVjyeal articulation ii? an iunjihiartbrosii* or mixe<l 
joint, fiu^ttished with a Hjaovial inetuhrnnc, and in movable ; 



i 



THE tySOMlSATE BOSK 



II 



that U, the chiJii's head fluriiig it« pAaeage out of tbe pelvk 
furces Ihe wxx'yx backward, tto aji to leave more room hetween 
its tip aud the Hyni|»h_>iii» pubis. In women pa*t the priue of 
life this joint tn^conK^t anohylo:«etl, the ctxwx refuses to yield 
before tlie advancing head, and hence ditficult labor. 

Fifik. It iif of the utmost importance to remember that the 
vertical meahuremeiit of the racrum aud cotryx, in the me<)ian 
litje — t. C-, from the centre of the sacral promontory above to 
the lip of the cocvyx below — the line of niensuremeut beiD^ a 
eJiord of the aacro-coccygeal cur\e — \» four iuchee and a half 
in length (4 J) or 11.4 cm. ; exactly thrre iimea as /ong qa ihe 
trrticul depth of the ^^phi^gis jmbist which is cue iach and a 
half (U)or 3.8 em. 

The Cocctx. — The coccyx ie triangular in »hape. It ia 
composed of four rudimentary (caudal) venebne, which di- 
miuijih in size fn>m atM>ve downwnnl. Ite hti^e is attached to 
the lower extrejnity of the eacrum, as already explained. 

Thk Inxomisate Bone. — The internal a»|>ect of the bone 
only rHjuire? Mudy. There we find a prominent line or ridge 
l>eginning at the t^acnnliac ttynchondruMM, a little below the 
level of the sacral promontory, and extending obliquely for- 
ward, i^lightly downward, aud at the tame lime dtvcrihing a 
Hunewhat «?niicin*ular cun*e inward toward the median line, 
where it eventually joins its fellow of the oppodtc side at the 
Rymphyuifct pubii^ ; this line is the linea iUo-pectinea of analo- 
iniMP. It tbrnis, wilh the f^cral promontory, and two short 
ridges cnwaing the wingH uf liie t^acrum between Ihe promon- 
tory and »acro-iliac synchondroite*, a port of cordiibrm outline, 
which in, in fa<-t, the brim of the pelvic biu^in, or, technically, 
the jnipenor xtrait of the pelnti. To recapitulate, the entire 
contour of the piifit*rior Htrait may be ihuf* described: Begin- 
ning in the mediau line at the centre of the sacral promontory, 
it paaKS outward acn>Hi* one latenil half of the prnmonlory 
intil reaching ihe wing of Ihe wjcruni, then acroea the wing 

itward, forward, and f-lightly downward, until reaching the 
-iliac Hynchon<l^oKi^ then it tnivcrn-H the ilium uud pubis, 
as juM dcK'rilted, along the liuea ilii>|»ectinea. until arriving 
at the Hpine of the pubin, and from thence to the tmnphypis 
pubiH, aud so on buck, over the op|K«ite Jiide^ uutil again 




20 



LNTSODUCTWN. — THE PELVIS. 



i 



reaching the centre of the sarral promontory from whence it 
started. (See Fig. 1. [wige 18.) 

The "false" ixjlvis, so-callod, is* nil that jHirlion r>f the 
pelvis situated above the superior strait, and i* made up chiefly 
hy the wings, crests^ and spinous pny^esst?* of the ilisK- l>i>ne8. 
Its Iwuy wall is deHL*ieut in I'roul ; hence il is, of tuurse* au 
iinperfeot or •'false" hasin. 

The •* true " pelvis is ail that |)ortion of the hasin nituated 
bfhw the hrim. Its cavity is a little wider in every diretrtion 
than the hrim itnelf, while the false |)olvis is a great deal 
wider; the hrim ip, therefore, a tnjmewhat narrowed bouy ring 
or aperture hetweeu these twor hence the term *' strait" is 
given it. 

In the cavity of the pelvis we find, on each side, the promi- 
nent tepine (spinous process) of the \Jickiitni and the iiicihted 
plana of the ischium. The Lschial npiuous pnx^e-ss |>roject« 
from the posterior b<jrder of the twiily (jf the Ixjtie, atK>ut mid- 
way between the highest Iwnler of the great sciatic notch 
above and the lowest margiu of the tuberosity of the ischiuru 
below, lis tip points at once downward, backwunl, and in- 
ward toward the median line, and extending from it forward 
and upward towani the upi^ir nmr^rin of the ucoTahnlnru is an 
indistinct ridge of Iwiie. Now the sukmjIIi, i^lanUng inlerual 
surface of the ischium in front of and Indow this indistinct 
ridge is called the miterior incfiued pfane of the iackiuw, or 
the anterior inclined plane of thti jtdriji — no nmtter which. 
Note, however, its direction : it slants downward, furufinf, and 
inward toward the median line ; so that a ronridefl holy like 
the fcntal head, cimiing down from alnive ami iTiipinging npOQ 
it, would glide at once fowrrr (hncu, vupvn furudnl, and also 
mward toivard the pidiic symphysis. Hei»ce it is instrumental 
in producing what is rnllcMl '^anterior rvtation" of the occiput 
in the mechanism of Inhor. 

Of course, there is an "inrlinc^l plane" of this sort on Iwilh 
Bides of the jjelvis, called respectively the ritfht and left ante- 
rior inelineil planes. 

The poaierior xndined planes of the pulvijn are rather difficvdt 
to define, but we may map them out as follows: Draw a line 
on the inner surface of the |>elvic cavity fn:»m the /y/moiw pro- 
fess of the ischium to the ilio-peclineal eminenrt (in most pelves 
an indistinct ridge may be observed along this line). This 



THE SACROSCfATIC UaA^fENT& 



21 



line divides the anterior from the |>osterior ini'ltned plane. 
liut as there is only a Mimll ruiniiiiiiiif: Furlhce of* the ischium 
hf'hiiul th^. dividing line to forfti (he jHtgirnor pltiue, it is evi- 
dent thitt, in the living woman, tliin phine is nini{>leted hy the 
8arn>jM*intir ligaments and the nuistuhir structures, etc,, that 
till up and cover the aaero-sciatic toratnirni. Jn a drift! [)elviH, 
therefore, ei*i)ecially when divct*ted of its HKTo-sy:iutJc liga- 
ments, it is iMJK'^iljle to see only >t very hiihiII [mrt of the |k»- 
terior incliue<l plane, viz., that part where it t»egin8 on the 
bftek of the dividing Hue ju^t iiieutione<l. Its coutiuuauce or 
extension downward aud liuckward to the median line of the 
hollow of the sacrum can <mly he seen when the muscles and 
ligaments are intiict ; and of which, in fact, the larger portion 
of the posterior incline<l plane is made up. 

The posterior inclined plane cauHer^ the pre*ienting part of 
the chihi impiuj^anj.' u|)0a it to rotate downward, bachcurd^ 
and inwanl lowanl the mcdiun line of the sacrum. Of course, 
there i» a [)o8terior inclined plane on each si^ie — right and left. 

Complete oasificjition of the [jelvic Iwne* doea not lake i)lace 
till aliout twenty years of age, which affords a prohahle explu^ 
nation why a fin*l lalwr is generally more eawy during the early 
part of a<iult life lhai» later. The iKme** yield a little, ana, 
after lalior ia over, the jwlvw prohahly retains to some extent 
the size and shape acquirt<.l liy the first early delivery, so ns to 
render Fuhfe<pient hib<trs more easy. 

At^er thirftf yean* of age the mcro-coccygenl joint may 
tioconte firmly anchyloniMl and <jtwifieii so as to prevent yielding 
of the coccyx l)efore the pressure of the child*8 head, thus 
adding another obstacle to delivery. 

The Sacrobciatic Lioamkntk — The greater sacro aciatic 
ligament (sometimw* calle»l the "|»o«tprior" one) arit*eH from 
the |Mtsterior infert<>r spinous pn)ce*w of the ilium, the lower 
part of ihe Irtti-nil margin of the sacrum, and from the coccyx : 
it if* inaerteil into the iubfroeiUj of the iwdiium. The l<4i»er (or 
••anterior") .stwro-sciatic ligament arises from the lateral mar- 
gin of the sucnim and coccyx, and is inserted into the spiiwut 
proct'tt» of the ischium. 

ThetH? liganu'iilH convert the great sciatic notch into the 
great sciatic fonimen, and the U*««er sciatic notch into the 
letEter siMutic foramen. 



22 ISTRODVCTIOy.—THE PELVIS, 

Thk Great S.\tK(»-H(iATii' Foramkn transmits the pyri- 
furmis miisK^lo, the ^liiteu! v«*st'lf* and nene, the iKc*hiatic 
vessels and uerves, the internal pndic vew^els and nerve, and 
the nerve l<> the ohtiirator interims muscle. 

The Lesser SArRo-sf'iATic Foramen transmits the tendon 
of the obturator Intenujt} muscle, its nerve, and the iutenial 
pudic vessels and nerve. 

The Obturator or Thyroiij Foramen is situated in the 

antero-lateral part of the jH^lvie wall, ijctween the puhii* and 
ischium, sometimes called the " furameu ovale." It is bridge*! 
over by a strong menihranoiis wch of ligamentous tissue, ciilled 
the obturator tiu-mbrane, fnjni the inner and outer surfaces of 
which arise, resjiectively, the internal und external obturator 
muscles. The ol»tumtor vessels iuul nerve |iass ihrcm^h an 
aperture in the up(>er margin of the oluuralur mendtrnne. 

The PrBic Arch is formed by the two descending rami of 
llie pulw^, and (in the femnlej ils inner ynt«M>tl) surface, lined 
at its central up|)er juirt by the sub[njbir ligament, is of such a 
size and sha[)e as to \ye altsolutely in unison with and a^bipted 
to admit the passajre of the sides and base of the oecipital j>ole 
of the fa?tal head, us we shall see in des4'ribing ihe aicc-hanisin 
of labor in vertex presentatious. 

The Inferior Ktrait or "Outi.kt** of ttik Pki.vih. — 
The dried Imiiy pelvis, diveslwl of ils niuwuhir ap]>cm]age8, 
is a basin without a Ix>ttom. The opening where the bottom 
ought to Iw is the inferior strait or outlet. Its contour may be 
dewribed, in particular, us follows: Beginninjj at the summit 
of the pubic arch, in the nu'dian line of the body, it f)asst8 
downward and backward along the inner margin of the de- 
scending ramus of the pulH-s an<l the ramus of the ischium 
until reaching the tubentHity of the iscbiuni, then along the 
great «icn>sr;iatic ligament to the side of the sacrinn and 
eotvyx, and tip of the latter b(me ; then back along the op|>o- 
site side of the |>elvis to the point of starting at the pubic arch. 
(tJeeFig, 2, page 23.) 



ARTICDLATrOSS OF THE PKLV/S, 



23 



ABTirULATIONS OF THE PeLVIH : 

Firi*t, The biii«e-joint of tht Xuiae of the coccyx with ih*- 
apex nf t\w Karruin (the mcrthrocctffjrai nrtifultiiiou). 

Second, The junctmn of (he auri<ulur-shtniefl nrticiilur i«iir- 
face of tlie side of the HUTiini. with ii similar shn|»e<i Huriuce 
upon the atljacent ilitini, the artirxilar surfiu'e on Iwth bones 
rovere*! by a plate of cariihige. This is the mu^o-Uiar ityn- 
chronHroniis. 

Third. The ^t/ynphtffiU pnbijty formed by the apposition of 
the two boiliet} of the pubic iHniea iu the meiliau Hue. The 
articular 8nrfac*»ii nre roughened by a series of nif)ple-Hhnpo*i 
prujectionB which dip into (he layers of curtihige that cover 



FiO. 2. 




laftrioritralt, or nutlH of pelrli. 

iJiPin. These plates of cartilaire are thicker iu front than be- 
liiiKJ : they aUo divcfire from each other |K>HleriorIy, ei-|K»t'iully 
at the up|>er part nf the artirulntion, leaving a little space 
wliich is txrupied by a fynovinl membrane, while lower down 
the interariiiMilar j-pace is fillHl with tibroun elastic tissue. The 
joint it* further strenfrthened by several layern of the anterior 
pubic li)ij^nient in front ; the piwterior pidiic lijjanient behind ; 
the EtU|)erior pubic ligament aUne ; nn<1 Itelow by a thick, 
triangular arch of ligamentous tissue (the subpubic ligament), 
wliich forms the upper bt»undary of the pubic arch. The joint 
18 rendere<l still more f^cure by the deiine membrane of the 
deep [>erineal fas-ia (trianjrular li^mment^ the apex of which 
is attuchefl atKtve to the Eiyuiphysis pubis and subpubic liga- 




24 iNTnoDVcrrox.—TnE pelvis. 

raent, aiul pxlendfi luU'rally to tho rami of the istihia and 
pnliH:*, thus liraciii^ i\w HJtlt^ nf the arch toother as ihi' Hides 
ol* the gahitM»u(l of a htJiine uro briu'ed together by cniss 
ti 111 born, 

Fvttiih. The lumhn-mrrnl tirtirnlation, where the inferior 
aspect of the IhmIv of the last Inmbar vertebra U'overeil with 
rarlilu^e) rests nfMin the snpfrior i»iirface i^t* the hnjje of the 
namiiii, which is also covered by n cartilaginoui? piale. These 
two layers of interveriebrul cartilage are niueh thicker in 
front than Wiiiid. whieh, of (x>urK!. tilts tlie wiicruin Utu-k- 
ward, and rontrilxitea to torm the promontory. 

Fifth, The hi^t-joiitU but with reyard to this we nee(J only 
reniemlx^r the poaUitm of the areliibnluni in relation to the 
pelvic brim ; it irt situated near tlie aulero-tatcnil jMirt of the 
brim's circumference — in fact, nc4irly obli<piely opjxwdte the 
aacro-iliac HynehondroHis (►f the other side, vvhicli is, of eonrse, 
placed in the jKi^ffnt-htt-rtd |>art of the |>e!vic circunifereuce. 

Planes of thk Tllvih. — The iitcHufd planes of the 
iachiura, ftoinelimei* called incHnfJ planes of the jn-lvu*, already 
studied, havo iiolhin;,' whatever to do with the planes of the 
brim, outlet, and (wlvic cavity, now to In? eimsidered, Ijet it 
l>e distinctly undei-stixwl that the '* planes" ntnl " htcHued** 
])lunps are different (hinj^s. 

If we fill an onliuary basin with water, and float upon the 
surface a disk of |mj)er whose circumference shall accurately 
fit the rim <if the Imsin, the surface of the |Mi|ier disk wowhJ 
represtent the pianr of the Irrim of that [mrticular basin ; in 
like manner a disk of pat>er pla^^d in the sujierior strait of 
the (»elvis so that it.-* circunifereuee accurately fits the contour 
of the |>elvi<! brim, would reprt^sent on it« purfare the ** plane 
of ihr Huprrior ^^-oi^'^or brim, of the pelvic basin. A disk of 
jiapt^r, similarly place<i, in the outlet or inferior strait, would 
represent on its surface the ^* phiue of (hf itiferior strait" or 
outlet, of the pelvis. The surfacefl of other disks placed at 
intermediate depths lietween the sujx'rior and iiderior straits 
(Buch vin mi^ht l>e imitated in the eiirtheu basin by its different 
decrees of fulness) wouhl constitute plnncH nf the peine cwity, 
which latter might, of course, Ih» nuiltiplied in uunitH'r indefi- 
nitely. 

The axis of the plane of the superior strait is an imaginary 



PLANES OF THE PELVIS, 



2S 



liue itftaBiog (hroiiyh the mitre of the pinne, atWi;Af avgUji to 
iM Anrjncr^ jimt n8 an axle-tree |ia«Bes at right auglcH through 
the centre of a curt-wheel. 

Owing to ihe. anterior inrliuntion of the ]K»lvis when the 
woman :4anilB ere<rt, the l)rini is, t\» it were, tiller! up l>ehind, 
so that the plane rest** at an angle of ahout til)"^ with thp hori- 
zon. Hence, therefore, ita axii', ini>tead of heiiig vtrlical, is 
so »Hspofie«i a.** nearly to agree with a line dniwti from the 
umhilicus to the coccyx. 

The plane of the outlet is more nearly horizontal thai» that 
of the su[»erior strait, IhiL it is Hlill elevated posteriorly, bo 
that a line drawn fn>ni the tip of the coccyx to the highest 
[K)int of the puhic arch will meet the horizon nt an angle of 
alK)ut 11°, which, however, is subject to variation, inasmuch 
ai3 the pre«*ing bark of the C4)n'yx during lal)or al«t prej*es its 
lip iimvmntnl to some extent, which, of oonrse, renders (he 
angle more acute. The axin of the plane of the inferior strait 
nearly agrees with a liue drawn from the tacral promontory 
to the anterior verge of the aauR 

The axes of the planes of the pelvic cavity are lines drawn 
through the centres of the planer at right angles to their sur- 
face. The axes of a great numher of surh plane-s place4l end 
to end, would form an imperlectly circiihir curve, or at least 
a |)olyhedral arc of a cur>'e, which wtmhi represent the real 
aji» of the pi-Mc cavnt. Carus attenip|p<l (o descrilie this 
curve (hence known as "Cnrus's curve") by placing *Mie leg 
of a pair of compasses on the middle of the posterior ei\f^(^. of 
tlie symphysis puhis (in a hisecte<l pelvis), the other leg of the 
compflfw having its point placet! midway between the pubis 
and sacrum, and l>eiug moved so an to describe a curve from 
the superior to the inferior strait. But the true axis of the 
pelvic canal is not so ge<>melriciilly |>erfect an arc of a cinde 
as to admit of being drawn in this manner; it is more nearly 
the curve of an irregular [mrahola. (See Kig. I^, page iiti.) 

The p**lvic canal in the living female does not really termi- 
nate at the inferior strait In wj far ns its osseous whUh are 
LXincerne*! it does, but the muscles and so(\ parts below form a 
continuation of the canal, and when these are stretched during 
parturition the |)osterior wall of the lower muscular part of 
the canal, viz.. from the coccyx lo the mouth of the vagina, 
nieasun^ quite as much us does the upper bony part, viz.r 



26 



ryTRODUCTiO.W—THE PELVIS. 



from the coccyx tit the wicnil |irnihontory. The ankrior wall 
of the miiwular jmrt of the |in«sjij|re, corresjMJiuiin^ wiih the 
pubis of the Immiv jtHrt. i.s of nmrn*, tleficieiit^ dihI necessarily 
BO, or the cliiM coulU never he estruiled in deiiverv. (Sec 
Fig. 3.) 

The temale (lelvis iliffeni from that of Lhe male exactly io 



Fra.8. 




Axis of the pvlvir canal. 



thoiae partirulare whicii render it l>etter adnpteil to faoililate 
fjarturition, notably (tirst) in t>einjj altogether wider in every 
direction, wliich (jrives ihotp room for the child tn pnw ; and 
(second) in being altogether ithalhwer, which fenxtiin the dia- 



PROOF THAT JOINTS YIELD DUniNQ LABOR, 27 

Umrv. lliroiij^h whidi thr rliild Iihh l(» ht* propelled \ and (third) 
the Iwnes* are thinner ami uniouther. 

fn rhe fcniale j)rlvirt thri [mhic arch i« hniftder and ntunder, 
the hollow of the wirrum i** less cur\e<l fesjiet-iuMy a* rejfard** 
its three n|)|>er se^rMieiits, which are iihnnst straight), the 
ohturatnr foramen in larger, nud a little farther, laterHlly, 
from the syniphys-is pubis; the MK'nil pnmiontory, iM'hial 
spinous prm-eHses, and tip of the eoeeyx are less prominent («o 
that they encroach to a less degree uptm the cavity of the 
pelvic canal), and tlie sacro-^ciatic notches are more gjmcioiw 
than in the male. 

Changes TAHTN*! i'Lace in the Female Pelvis toward 
THE Eni> of PKK4;NANrv. — The interarticular cartilages 

.become thicker ; the ligaments ttnfter and mmrwhal reiuxed; 
Bynovial tluid in formed more plentifully in the articidatious ; 
and the joints bwome, Ui an cxttedingly UmiUd cjiciit-, tn^n'^^bl^, 
so a« to l>e <*ai>able of yieldiriiu: a very little, if ne<-'eaear>', to 
permit the pawa^ of the child. The swidk^n ciirtilji^'cs also 
act sm cubhions Iretween the bones* thuw leweniug the mechan- 
ical shock of falls, jars, etc., somewhat like the *' buffers" of 
railwav cara. 



Proof thatthf Joi?rr8 AmTAi,i.v YtELD ditrin(j Labor 
is inferre<l not only from the fact of it?- wcurrence in the lower 
RDimals (in the guinea-pip the symphysis ])nbis separates an 
inch, so that the sacroiliac nynchondrotiis jilays the |»art of a 
hinge-joint ; and in the cow the sacrum sinks down Wtween 
the innominate boncss so as to push them wider a|>art », but also 
from the circumstances that in women dyinjr during lal>or sepa- 
ration of the bones has been found on ditisef'tion ; and in certiiin 
cases where the physiidogiail hH>sening of the articulations has 
l»een |»atholt»gicaIly exaggerate*!, hxN>molion has l>een inter- 
fered with, an^l the pubic symphyt-is found sepantted an inch 
or more. Again, if the pulp of the index tiuger be placed upon 
the lower end of the symphysis, at the sunmiit of the pubic 
arch, and kept there while the woman walks, or stands first 
on one foot, then on the other, the l)onos on each side of the 
eyniphysis will be felt to glide up and down with each step, 
the side eorre$:pcmding to the advancing limb U'ing lower than 
the other. This is more marked in mutti^mne: may \ie unap- 



28 




INTRODVCTION.^TRE PELVIS. 



preciaMe in primipanc. It can be observed toward the end 
of pregnancy. 

Measurements of the Pei.vib. — Tbe object of measuring 
tht^ |)elvis Ls tn eonipare tbe length uf ita dianicterH with the 
diameters tif the child that pa^^ej* tliroughit; without this it 
would be itiip(»<Hihle to uuilenituad the mecbnni^iii of laT»or or 
to render suitable aswistanee in ca.*ei» of 4iitbrult delivery. 

The size of the pelvis is not the nime in nil women. It 
differfj in dilfereiit raeeg of mankind and in diH'erent indi- 
vidual of the wime raee. There is no rejourn why the pelves 
of any two wunieii should be more exa<'lly alike than the 
leni^h of their feet or the features of their face**. 

There are no mentis by which ive can meutiure with [irfcision 
(flay within i>ne-tit\h or even nne-fourth of an iiR-h) (lie diam- 
eters of the pelvis in a livinfr female ; itur meaynrements 
under such rirfuniMancei* ran only npproximnh' the truth. 
Keither are there any nieiina by wlneh we can measure any 
more aecurately the tlianieter of a eliildV head before it is 
Iwrn ; we ean scarcely do l)etter than guesB even its approri' 
maU meJumremenlR. 

Ilenee there ig no praeli<*al use in trying; to define and leach 
the meawnrementH of the averape fenmle pelvis with that 
extreme preri^^ion (down to tbe tnialler t'rariions of an inch) 
attempted in many obstetric text-lKK)kh. It complicates the 
matter without any s()e<rial nilvantage ; an approximate pre- 
cision is all that b retjuisite — all that is po^ihle. 

Diameters of the Superior Strait (see Fig. 1, page 

Fir«L The an^o-7w«/mor (saero-pubic, "conjugate." *'«>«- 
jugnta ivra,*' or true eonjtipale), extending from the middle of 
the sacnil promonlorv to ihe top of the symphysis pubis. 

Sfcond. The ^wiiHjy-r^r (bifi-iliae), exten<iing acropt* the 
widest |>art of the iilrait, from one hiteral margin of the brim 
to tbe other. 

Third, The right oblique (diagtaialis dextra), extending 
from tbe right saent-iliac synchondnwis lo the left atrtahulum 
(or let\ ilio-peetineal eminence, which in nearly the Siinie thing). 

Fourth. Tbe left fthliqtie (diagonalis heva), extending from 
the left sacrtMliac synchondrosis to the right acetabnlmn. 



DIAMETERS OF THE INFERIOB STRAIT. 



29 



Fifih, The diagonal eonjugcUe (conjugata diagonalis), ex- 
tending from the middle of the sacral promontory to the lower 
end of the pubic symphysis. Since the pubic end of this 
diameter is really at the inferior strait, it is not, strictly, one 
of the diameters of the superior strait, but a diagonal between 
the two straits, as its name expresses. (See Fig. 4, rf-c) 

Pro. 4. 




e-r. Oonjugate diameter of Bupcrior strait, d-e. Diagonal conjugate. a~$. 
Axis of plane of superior strait. p~it. Plane of the outlet, or inferior strait. 
k-h. Line of the horizon. In this figure the woman U suppoeed to bo standing 
erect. 

Diameters of the Inferior Strait (Fig. 2, page 2^) : 

F^rgL The antero-posterior (coccy-pubic, called also ** con- 
jugate"), extending from the tip of the coccyx to the lower 
end of the symphysis pubis. 

Second, The transverse (bis-ischiatic), extending acniss the 
outlet from one tuberosity of the ischium to the other. 

Third. The oblique (of which, of course, there are two. 
right and leil, as at the brim), extending from about the 
middle of the lower border of the great sacro-sciatic ligament 
of one side to the thickened portion of bone where the de- 
scending ramus of the pubis joins the ascending ramus of the 
ischium, or thereabouts, on the other. 



30 



INTRODUCTWX—TUE PELVIS, 



Diameters of thk Peia'ic Cavity : 

FimL The tutierthjmnierior (conjugate), extending from the 
centre of the eymphysis pubis to the centre oi the hollow of 
the sacrum. 

St'cimtl. The frftrisi'er/fCt extending iut<is.« from a [Hiint nearly 
op|>osite the lower wlge of the a^-eUhulum on (»ne side to a 
correp[>ondinj; [M^int n|Min the other. 

Tkini. The oh/ique (of which there are two, right and left), 
extending frum the centre uf the great Hacru-scialic foramen oa 
one side to the ohturalor foratneu on the other. 

(The diameters of t\m cavity art: nut ^ impurtaut an thoee 
of the brim ami outlet. ) 

TiiK AvFRAuK AiTKoxiMATK LENGTn of the diameters 
uf the i^elvic canal in the living woman is aj} follows: 

Aiiten>jx)slerior of the brim, or 

superior strait 4 iDches, 10.1 cm. 

Transven* of the brim iu the 

living female 4 inchea, 10.1 crn. 

(The transverse is 6 inches, 12.7 cm., in the dried pelvis* 
owing to the removal of the jieoas magnus mus^-le, which 
takes up half an inch of space on each side in the recent 
pelvis.) 

Obliques of the brim (right and 

letl alike) 41 to 5 inchets 11.4 to 12.7 cm. 

Diagtmal conjugate . . . . 4^ inches, 11.4 cm. 

Antero-|X)sterior of the outlet or 

inferior strait 4i to 5 inches, 11.4 to 12.7 cm. 

TransverJ*e of the outlet . . 4 inches, \i\A cm. 
Obliques uf the outlet (right 

and left alike) 4 inches, 10.1 cm. 

Anterioposterior <d' the cavity . 5 inches, 12.7 cm. 
Transverse of the cavity . . 5 inches, 12.7 cm. 
Obliques of the nivity (right 

and left alikcj r> inches, 12.7 cm. 



DIAMETERS OF THE PELVIC CAVITY, 31 

The most important fact developed by these measurements 
is that the brim is longest in its oblique diameters, while the 
outlet is longest in its antero-posterior measurement, which 
explains the necessity of what is called "rotation" in the 
mechanism of labor. 

In addition to these measurements of the pelvis it is neces- 
sary to remember the depth of its walls ; thus, the depth of the 
anterior wall — i. «., from the top to the bottom of the sym- 
physis pubis — is li inches, 3.8 cm. ; while the depth of the 
pofierior wall, from the sacral promontory to the tip of the 
coccyx (the line being a chord of the sacro-coccygeal curve), 
is just three times as long, viz., A\ inches, 11.4 cm. The 
depth of the lateral wall is not of much importance ; it is 
about Z\ inches, 8.8 cm. In measuring the pelvis of the living 
woman exUmaUy, for the detection of deformity, it is especially 
necessary to remember the following : 

1. Between the widest part of 

the iliac crests (inter-cristal 

diameter) lOi inches, 26.6 cm. 

2. Between the anterior supe- 

rior spinous processes of the 
ilia (inter-spinous diam- 
eter) . 9} inches, 24.1 cm. 

3. Between the front of the 

S3rmphi8i9 pubis at its upper 
end, and the depression just 
below the spinous process 
of the last lumbar vertebra 
(conjugate diameter) . . 7| inches, 19 cm. 

4. Between the anterior superior 

spinous process ofone ilium, 
and the posterior superior 
spinous process of the other 
(the oblique <lianieter) . . 9 inches, 22.8 cm. 

In measuring the conjugate externally, a deduction of 3} 
inches (8.8 cm.) must be allowed for the sott parts and thick- 



32 



JSTRODVCTIOS. — THE PELVIS. 



nttt« of the Ituiiuia, which, when tfulitnit'te*! from the 7i iiichte 
(19 cm.) of the external meai«nrement, leaves 4 inches (10.1 
oni.) — the normal conjugate of the brim, internuUy, a» we 
linve already seen* 

The above ineji.**tirenient*», of i-ourw, refer to normal pelves. 
Numerous other riu?ui*ureinenlis eniploved for the dettn'tiou of 
special forms of pelvic ilefurmity, will l)e couHJdereii with the 
din^osis of thone ai»uormalitieti% (See Chapter XXII, ou 
" Pelvic Deformities.'*) 

Muscular Structures of the Pei,vis. — Above the brim 
the muscles of the aMominal walls wmiplete the wall of the 
** false" pelvis, where 'Wn Ihjuv wall is deticient iu front, and 
they form the alKiominal cavity, nntfed al>ove by the dia- 
phraj^m» which agreeH Homewhat in Hha|>e wilh the full-term 
gravid uterup, so that by the ntntrartiott of the nbdoniimil 
muscles and diiiphrajrin during the paiiw of laln>r the womb 
ift ti^'hllv embraced by them, and aA«isted in ita expulsion of 
the child. At the brim we fitid the pHoiw maj^nnst, which, 
nripin^ from the side of the lii^t dori*itl and from the sides of 
all the bnubar vertebrae, |>a.si*ed di>wn and cro!fc*ea the brim, 
where it takeri up half an inch of a{)acc at t^eh end of the 
transverse iliameter of the superior strait, to be ineerled, wilh 
the conjoined tendon of the iliacus internus miiwle, into the 
lesHer tnichrtnter of the femur. The a<?tion of these two 
mnsele*» in to Hex the thi^h ujmhi the j>eIviH and rotate the 
femur outward, and as this is the fHieture usually [LHsume<l by 
the jmrturieut feuuile. the muscles are prevented from being 
«trelche<i taut, and thereby eucroach less ou the briui aud thus 
offer less obstruction to the passaf^e of the child. 

Structures forming the Floor of the Pelvis and 
MAKiNo A HorroM TO THE Basin. — The |telvic floor ("|)elvic 
diaphra>rm '* ) is com|>osed, chiefly, of fascia, muwleis, and 
connective tissue. Its sujierior surface is lined by |»eriloneuni. 
Next below, and in cUtse contact with the t^eritoneum, com(« 
the tough, elastic, "internal |)elvic fascia," which i« attache*! 
to the i>plvic brim. Here it meets from almve the fascia 
transversalis of the alxloniinal wall and the fas<^ia lining the 
iliac fosese. Below the brim it is finnly attached U\ the peri- 
osteum, aud forma a tendioous arch {arcw iendinextA) re-acliing 



i 



STRUCTURES FORMING THE FLOOR, ETC. 33 

from the ioDer border of the ptiltes to the spiue of the ischium ; 
from this arch it extends to the nie<lian Hue of the body. Im- 
mediately below the internal j)elvif fascia are two thin mus- 
cles, viz. : 1st The Itmior «»/, each half of which arises from 
the body and horizontal ramus of the pul>es and from the arcus 
tendineus, and passes downward and inward to meet its fellow 
of the opposite side in the median line, where it is inserted 
into a tendinous raphe extending from the coccyx to the rec- 
tum, while some fibres pass l>etweeu and to the sides of the 
bladder and rectum, and to the vaginal and rectal sphincters. 
2d, The uchio-coccygeus (called also simply *' coccygeus "), 
which is a narrow, triangular slip, situated [uirallel with aad 
posterior to the levator ani, closing in a little space which the 
latter muscle, as it were, faileil to cover. It arises by its apex 
from the ischial spinous process, and is inserted into the side 
of the coccyx. Below these nuiscles the |)elvic floor is further 
strengthened by another layer of ikscia — the perineal fascia. 
Its posterior portion — consisting of a single layer — is attached 
to the sides of the pelvis and arcus teudineus, from whence it 
is reflected over the inferior surface of the levator ani muscle, 
while its anterior part is <livisiblc into a deep layer (covering 
the lower surface of the levator ani), a median and a superficial 
layer. Within these latter layers are lodged the pudic vessels 
and nerves, ami the su{)erficial muscles of the perineum. 
These muscles are (1) the con:<irietor vagimr, each lateral half 
of which arises, jjosteriorly, from the |)erineal fascia midway 
between the anus ami is<-iiiuni (a small slip only passing to 
join the sphincter ani muscle), and pa-sses forward to unite, by 
aponeurosis, with its fellow of the op{)Osite side, near the clitr 
oris; (2) the f*phine(er ani, which arises from the tip of the 
coccyx and is inserted into the tendinous centre of the [teri- 
neum ; (3) the trnnifveri<iit< periuei^ a narrow, transverse slip 
arising from the ns<'criding ramus of the ischium, and inserted 
into the sides of the vagina ami rectum. 

To the several structurt's of the |)elvic fl(M)r alwve given 
must now l»e addiMl the intcgnmciit and the very numerous 
interstitial layers of ela.^(ir ronncclive tissue, which latter weld 
the |»arts together an<l adtl strt'nglh an<l elasticity to the whole 
fabric. 

HeHi<les their nn>tor function, the niusch-s covering the itincr 
surface of the |»clvis (including the pyritonnis — not yet meu- 
3 



34 



THE FCETAL HEAD, 



tiouetl — which arises chiefly from aud oovers the hollow of the 
sacrum* provide a sort of muwiilar uiiholntery to the interior 
of ihe iK'lvit*. hy which its luniy liiu« ami proiiiinences are 
cnshioiu'il (tver, sn as to ])reveiil injury In ihe !*ort parts during 
the pa»<apo of the chiM, while ibu iiiiiiut itself reccivee the 
same prolectiou. 



CUAPTEK II, 



THE FfETAL HKAI). 



TfiK head of the fa'lus re<(uireii f«|)e('ial study, heoauso^ from 
its «i/x* and iiu-oniprtssihility, il i?* the most diiiicull part of the 
chihi to deliver ; wh^Mi ihc liead i?* tH»ni. the rt-^^t of ihc labor 
w usually completed iu a few mimitcs. The child's lioad, how- 
ever, is [1(4 alisohitely iiicoinprcssiMc. It?- bony wall ]>; clajitic 
to n certain cxtcivl in all parts except the base. By this ar- 
rangemeDt^ yieldhig of the Ikuics permils [ircssure only upon 
the upper part of the fa*tal brain. whore» when moderate ia 
degree, it is harndi-st* ; the same pressure upon the Ikiac of the 
brain and meduUn would l»e tatal. While it is not true that 
the short traiisverm* diameter of the child's head, viz., from 
one parietal prrftuberaiice to the other, is less than the trnns- 
verpe diamett^r nf the trunk, viz.. fmm one nrrmniotj process 
of the scapula to the other, still tl»e boiie^ and niuseles of the 
arms, shouhiers, and trunk arc so niohile and flexible that, 
when they are jammed into the iK-lvis, the liisjU'romia 1 *iiameler 
is capable of being easily reduced to a less wiflth than the 
transverpe diameter of the skull ; hence the heji<i, though 
apjwirently no/, practically is wider tlian across the shouldexs. 

Bhape of tiik FarrAL Hkai>. — This does not correspond 
perfectly to any ireometrical fijrnre, but it will best suit our 
pur|M»se to consider it ovoid or e»;^-sha[M^d — the cliin corre- 
sponding to the small end of the ejrjr, tlie occiput to the large 
end, an*! the widest transverse cirenmtiprencp j»n>5^in^ over tlie 
parietal protuberances. One as|M!ct of the ovoid, viz.. its base, 
is considerably llaltened, and eo are the sides of the head, but 
to A less extent. 



FONTANELLES. 35 

The foetal cranial bones are imperfectly ossified (and are 
therefore elastic) ; their sutural borders are surmounted by a 
rim of cartilage, and the cartilaginous rims of two contiguous 
boaee are only united by bands of fibrous tissue which become 
ossified later. The bones are further held in apposition by the 
dura mater, pericranium, and skin ; their borders, however, 
can be pressed closer together, or even made to lap one over 
the other, during parturition. The posterior borders of the 
parietal bones especially overlap the anterior borders of the 
occipital. The union of the npjier, squamous part of the 
occipital bone with its basilar |X)rtion l)eiug only fihro-cartilag- 
iuous in character, this junction is somewhat movable, like a 
joint; hence pressure upon the prominence of the occiput easily 
depresses its anterior borders l>eneath the posterior borders of 
the parietal bones. The distance between the two malar bones 
can be reduced, by compresssion, only in a very slight degree. 

The base of the skull is sufficiently ossified aa to be i?icom- 
pressible ; it is, however, narrower than the top of the skull, 
and needs no reduction in size to facilitate its passage through 
the pelvis in ordinary cases. 

Sutures of the Cranium. — They are : 

Fird, The coronal suture (or fwnto-parietal\ passing be- 
tween the posterior Iwrder of the frontal Iwne and the anterior 
borders of the two parietals. It goes over the arch of the 
cranium from one temporal bone to the other. 

Second. The sagittal suture (or biparietal\ running along 
and between the 8U|)erior Iwrders of the two jmrietal l>ones 
and extending from the superior point of the occiput to the os 
frontis. It must be ni)te<l, however, that, in the foetus, the 
two halves of the frontal bone have not yet united ; they are 
divided by what is called the /ro»/o/ suture almost to the root 
of the nose, and by some writers this frontal suture is regarded 
as a continuation of the .sagittal. 

Third. The Inmhdmdal puture (or oceipito-parietai), running 
between the superior, or rather antcro-lateral, Iwrders of the 
occiput and the |>ostcrior lH)nlers of the imrietals, and extend- 
ing from near tlie mastoid pr(>cei*s of cme tem|>orjil bone to 
that of the other. 

FoNTAXELi.ES. — Thc fontautlks are spaces left in the skull 



36 



THE FCETAL HEAD. 



at |K)intB where ihe nn^lej* of two or ninr«* iiones finally meet. 
They are »lue to ilffirieut oeMtit^liou, aud are explained by 
the geneml principle rhiu asaificfliiou, lK*iriiiuing ni^ar the cen- 
tre of II l»one iiiul extending toward ith c'irowmfereiu*e^ reuchea 
the angles lost hecause thoy are generally t'urlhest from the 
eentre. There are six fontaoell{^, hut only two of them are 
of olwiletric imiK»rtJUiee. TherKJ are llie twter'nn' (or fmnt<v 
iHirietnl) fontaiielle and the fuMtrior (or iwripito-parietal) one. 
The sha|»e of the nnfrrior one may Ik? ap|)njximately de- 
fiorilwd by drawinj;!; line:* lietween the lour [Kjint8 of a eruriBx ; 
it ill a four-tiide*l tigure, two of whoH? t*ide!* are Hpial — lozenfr©- 
sh»|x*d — the hm^, aeute anj^le l>ein^ fonued by deticit-nt o»*ifi- 
nitioii iu thf |)osterior sujierior angh's of the two hulvw of the 



Fig. 5. 




SbowlDg the ahApe of foniai> i nj? acnte «nslo of ilic nuterlor on« 

pnJnttttK toward tbe nu»c. A-0. Hi]MrlcUt iHmnvtcr. 



frontal boue-, ai]<l the short obtui«e angle by detieieut os^ilica- 
tioii in the anterior superior angles of liie parictjil b(jue». Its 
situation is where the coronal suture ('ro!*i»e^ ihe sagittiil. lu 
size it is a eonsiderahle menibnniou.- Hpaoe, easily re<-ognlze(l 
by the finger, and ollen by the eye, and through it the motion 
of pub«ition in the n-n-bral arterieji may Ik* Iwith :*wn and 
fell. It in not complrtcly elo>*<Ml till one or two years af>er 
birth. Uemenil>(.T piirticiihirly that the i'/nff angle of this 
fontnnelU* |K)intH itiwarti the forehuud and noH4< ; the short laie 
towanl the oceiput, (See Fig. 5, ) 

The fHi>*tt'rlor fontanelle is much stoaller iti size. In-ing mniply 
A triangular iIcpre;«i(Hi Miluateil at tin- jioint where the sagittal 
fiiilure meets (he lamb<loidaI ; nuiiating from it are /Art-^rsulural 



RKOIONS Oh' Tim F(ETAL SKULL. 37 

arms, viz., the sagittal suture and the two arms of the lamb- 
doidal. It closes a few mouths after birth. 

The other four foutanelles, two on eaxrh 8i*ie, are placed at the 
inferior angles of the parietal bones. They are unim[)ortaut. 

Regions of the Fo-rrAL Skull. — One of the most im- 
portant is the vertex. Literally this means the highest part 
or "crown" of the head ; but when in midwifery we S[}eak of 
a " vertex presentation," we refer to a more posterior region 
of the skull, which 1 have already compare<i to the larger, 
rounded extremity of an eg^f^j au<l which has (I think very 
properly) been termeil by some writers the "olistetrical ver- 
tex ; " it may he defiue<l as a circular space whose centre is the 
apex of the posterior fontanelle, and the circumference of 
which passes over the occipital protuberance. 

Other regions of the fiptal head have l>een described, but 
they are not of great imiwrtance, viz., the '• base" or flattened 
surface directed toward the neck, and the facial, frontal, and 
lateral regioiis, which cxphiin tlu*raf»elves. 

The space occupied by tlie anterior fontanelle is sometimes 
called idncipuU or hrajma.^ 

Diameters of the ChiltTn Head^ and iheir Ajiproximaie Average 
Length., ( Fig. 6, jMige 38.} 

The ocdpito-inentalj extending from the 

point of the chin to the su|)erior angle 

of the occiput 5 J inches, 14 cm. 

The occijnto-frontal^ extending from the 

centre of the forehead to a |)oint on 

the me<lian line of tlie occiput a little 

above its protulHTun(!(^ 4i inches, 11.4 cm. 

The hiparietnl, passing transversely from 

one i>arictal protnlwrance to the other 3J inches, 8.8 cm. 
The cervifihbrt'gmniic (called also *'tra- 

cheio-l)regmatif " ), passing vertically 

from the |M)Htcri<tr angle of the anterior 

fontanelle to the antcri<»r margin of the 

foramen magnum ...:... 3i inches, 8.8 cm. 

' The terms "irrtrr," " finHimf," ami 'brrfjmn " are di-finod sa diffi'n'nlly by 
different authors ilial I Khali avdid uHiiiK thein hh far aH practiealilr. See 
Appendix on I'nirdrmity in NtHitenrhiture, etc., at the eiul tif thiM IhmiIe. 



38 



THK F(ETAL HEAD. 



The fronto-nuMital, p>iii)r fmni the lop of 

the tbretieuil in the end iff tliu chin . 3| inchoe, tkH cm. 
The bi-tem|x>rnl, jfoiiiu turnn^ Cnjin one 

temporal himv lo tho other, Im;Iw<^ii 

the two h)wer I'xlremilii.^ Mi' iIk- o»ro- 

mil suture S| indieft, R.2 em. 

The f!ulKxritut*>-t>re^umtic j?<»iujr from the 

union of the nerk antl iK-riput Xo tlie 

ceuire of the anterior fouljuieile . . 3i inehes, M.5 eiu. 

8evepnl other eniuinl (liiunelem are >riven in wmie of the 
text-U>(>kH. nnd the Duuil)er might U* in<leiinite1y nmltiplieil. 
but the fthovo are all that n'<piire to Ik' reiueiulH*rtHL' 




Diameters of fa-ul tiuad. 1-2. OerlpUofronul. 1-^. Occtplti-montal. 
b-fl. Curvlc^^brvfriuttllc lur vvrtli-ttl). 7-^ Pntnto^nicuUil. 

One other menstirenieiit /of jrreat importance when eoi^id- 
eriu^ the nie<'hani.*ni of fm-e prestrntatioiiH) may In* athle^i, viz., 

1 It dhouUi Ik? iioti'.l llist ihi- !ieH«J moy t»o pre***--! i>ul of lis nuliinit F<h«pe 
("mutililinl "! (luring iU-li\tr> , uiul lli»' illrrrtioii nf mii'ti ilUtiinlMn \« ||| vary 
with tilt.- kin<l hf |>rt.'ac-iiiui.iuii, uii<J coiuteiiuuitily tljccrAiiial dluiUL-trrB will 
Y«ry aicunliiiKly. 

Akaiii, l^t it In; rviuetuWrvil tlmt tlicutijcct (•riin^iuiirliiKany luiniculurfllnni- 
eU-r 1." !>' l:> I i)it' iliiiii ii>:i>n of ihi: homl In that ntii* ilirvctixn. itinl. %%liiU- uu- 
tlt' ' 'la to ()i<? rxart ttutru)' on the Akuli ai wliiili the 

I'll ' r< ure til tiv hUectl. Uir pruL-tli-Kl i»r)iirl|tk- In titiiu- 

iiriu- utl 'A'U* Tlii .'.iii.it 1 !ii.iiijii iiijiiiit i.-r 9init9 mt 

ihL- i-.iiitoi i;. lliiv of 

thf iKi'ipnl /*< ' ■ ; »fortM «l 

the roiiAt nnUTi' ... i , ;_._ ^ ..itnU t-iMtfl 

At a |Milut uti ttu- iiit'Utuii line t>f ilic ui-Lijtut jhrtJtat ftm*tt>€ti Jii/m tM point li^ 
tlurtiHt;: aDil a<> of tht othi>r dlameUini.. 



THE MONS VJCyERIS. 39 

the sterno-mental length of the chihl's 7teck when the chin is 
removed as far as ix)8sible from the sternum ; it is 1 i inches — 
exactly the same as the depth of the symphysis pubis. 

Articulation and Morevieuts of the Head. — The motions of 
flexioa and extension are provided for, in part, hy the articu- 
lation of the occipital condyles with the atlas, and, in part, 
by the articulations of the cervical vertebrae. The motion of 
rotation (which cannot be forced beyond the fourth of a circle 
without danger) is provided for chiefly by the articulation of 
the atlas with the axis, and partly hy the joints between the 
other cervical vertebrae. The articulation of the atlas with 
the cranium, being nearer the occipital than the opposite pole 
of the head, is of importance in promoting "flexion" during 
labor, as will be explained further on. (See Chapter XIV,) 



CHAPTER III. 

EXTERNAL ORGANS OF CJEN'ERATION. 

The structures generally included in the external generar 
tive organs of the female are : the mons veneris, labia majora, 
labia minora (nympha?), clitoris, vestibule, urethra and its 
meatus, the fossa navicularis, hymen, and carunculse myrti- 
formes. The term " vulva " is generally used to ex])re88 all 
of the genital structures just mentioned except the mons 
veneris. The term ** pudenda" has a similar meaning. 

The Mon8 Veneris (wioh/ de Venun) is a cushion of adi- 
pose, cellular, and fibrous tissue, situated uj)on the front of the 
symphysis and horizontal rami of the pul)es. Its thickness 
varies with the olw'sity of the individual, and its prominence 
differs acconlinjij to the degree of projection of the pul>es. 
After pul>erty it is covered with liair, an<l is abundantly sup- 
plied with sweat and sel>a<*e(>us glands. Its function is not 
positively known. It |K>ssibly serves the ptir|K)pe of a brow, 
in preventing irritating secretions from the skin trickling into 
the vulvar fissure. 



40 



EXTERNAL OROAKS OF OENBJiATfOK 



Tin: Labia Majora. rnlltfl alwi "Lauia Hxtkuna** 
Hnd " Labia PnnK\ni," are the li|»t* of the genital fissun;, 
placeil Fi*K' hy siflc in an antt'ro-[K>Kt*.'rior <lirvrlion. They 
in^^in Hi the hiwtT jmrt tA' ihp minis venerin (am if hv a hifur- 
eatioii iif timl .structure ), which ir' tiieir lliickot |Hirt, aiul jiass 
at tirj*t (hivviiwanl. then horizotitnlly backwanl, becoming 
thinner in their course, and join each other at a |Kiint alH>ut 
one inch in fnajl of the antif. Their jMtint of jnm'li<»n in 
fntnt is called the anterior rf$nimit*ittire, and their point of 
amMJsiiioii ^ tK'himi, the fHntfrrior cominitf^ttre, 

rhey have two siirtacfts an rxitnud Kurfaoe eovereil with 
ordinary skin, aliundanlly supplied with linir follicles and 
HeI)Uceous glands, and an ittUniutI surface, also of skin, hut so 
smooth an to he alna»st indi.<tingni?ihahle I'roni a mucous nieni- 
hraue. The Ininsitimi from skin t'j muc«tus nicnihranc really 
take.-« phuv in the hilmi minora, hence the covering of these 
hitter orirnns is dcscrilied l>y some wrileis as skin, fiy others as 
mucous nicmhraiie. 

Under th(> skin of the labia majora is a thin layer of nuslri- 
ateti niusciilnr tilircs — the "woman's dartos" — and beneath 
this, enilKMlileil in a<li|K>s(* and coiinei'tivc tissue, a p<*ar-sha(MHl 
sac, the niirn)W neck of wl»ich is continuous with the external 
inguinal ring. It is known ns " Unica's pouch :" (-(tniains fat 
and conne<;tive tisjiue, and occasionally, in young subjects, a 
prtK-esft of |M»riloncun», hniiKilnguns with the processus vagimi lis 
of the inaU'. known as llic "i-anal of Nuck." This canal 
usually Iwciinies obliientted, hut may sonietinies |K-rsi^t and 
iMvome the s<>al of hernia. It follows the course of the nmnd 
ligunient of the uteruis aonie of the fibres of which terminate 
in the labia majora. 

The F<wsa NAVirn.Anrs. — .lust before the labia come 
together (Misleriorly they arc united t»y a transverse Ibbl of 
mucous membrane /which w»niewhiif resendilcs the web «)f .*-kin 
lietween the tbnnib ami iiii'^'cr) i*nllcd \\\v fumvhrflf {i\i i'nenu- 
lurii puilendi). and the litlh', <le|ir*isM'<l space iM'tween this and 
the |H>slerior ctnumi^snre is the jimm i/«ric«AiWx. It is gener- 
ally obliterated iif^er lalwr by rupture of the fourehelle. 

' Tin- InhiB <!'« n<it \\\\\w fM^tcrlnrly nt nv'i»i]lr.\\n\ ninnhtR Bitk-by Fl<le, t'l<"» 
tocHch oUiiT. ilir viilviir linpun- trrnilnmi'f iti n miri **i Ititrizoiitil "mitU-r" 
rotttlim<iti« Willi Uh' iMTitieiini : luMir-? 1 hnvL* ajipUi-il Uie term ••nppiKtitltJu" 
hi.-li-nil iif ••junction " \*» lh»- iw*lmur unimi. 




THE VESTIBULE. 41 

The Labia Minora, or NvMPHiE, are thick* double folds 
of mucous membraue, Hlx>ut one inch and a half long, which 
begin by gradually projecting from the inner surface of the 
labia majora, mi<lway l)etween the two commissures. They 
then pass forward until reaching the clitoris, when they split 
horizontally into two folds. The upi)er folds pass above the 
clitoris, and, joining in the median line, contribute to form the 
prepuce of that organ, while the lower ones join underneath, 
forming its frcsnum. The nymphae are covered with tessel- 
lated epithelium ; they contain connective and muscular tissue, 
vascular papillse, and sebaceous glands. They are very vas- 
cular, also erectile, and secrete an odorous sebaceous mucus 
which lubricates their surface and prevents adhesive union. 
Their function is not certainly known. 

The Clitoris is a small, erectile body, about one inch in 
length, placed just inside the vulvar fissure, half an inch be- 
hind the anterior commissure. It is composed of two corpora 
cavernosa, which are unite<l in the median line and end ante- 
riorly in the glans clitoridis, but separate from each other 
posteriorly to form the two crura, which are attached to the 
rami of the pul>es and ischia. It is considered to be the 
analogue of the penis, but differs from this organ in having 
no corpus spongiosum or urethral canal. The vascular bulbs 
of the vestibule and the intermediate plexus of veins uniting 
them on each Mde with the vessels of the clitoris, would, if 
united in the median line, represent the corpus spongiosum of 
the penis and bulb of the male urethra. The clitoris has two 
erector muscles ; it is abundantly supplied with vessels and 
nerves, and constitutes the principal seat of sexual sensation. 
It is secured to the pubis by a sus|>eu8ory ligament 

The Vi-STiiiiri.E is a triangular surface of mucous mem- 
brane whose base is the anterior margin of the vaginal orifice ; 
its apex termiiiaten at the clitoris, and its two sides are bounded 
by the »ym|>hae. It is of little imjwrtjince except as a guide 
for finding the meatus urwanun, placed near it** lower margin. 

On each side of the orifice of the vagina, enclosed in a thin 
layer of fibrous tissue, under the labia majora, is a siwngy, 
oblong mass of small, o(mvoluted veins, which, when distended 
during sexual excitement, assumes, in its entirety, the form 



42 



KXTEHSAL OltGAHS OF GENERATIOX 



of a filled k'cch or of a (lirniiiutive lianann. Thette are called 
the bnihi vrMibuli^ wimetinuf ihe wnfinnl hulba. Their veioB 
are continuous witli ll)i)s(> (it* the clituri.s uiid vagiua. 

Thk Fkmai.k rKimiRA is oQe inch aad a half (u length; 
is larger lliuii ihat of iho male, and nit)r(' ea.^ily dilatable; it 
lR»i:inH !it tht' lueatiiN which is situaled iiniiieduil^^iy Iwlow the 
rim of the puhic arrh, and iiat«se.H ha<'kward, mrving a little 
uj>ward. tu the neek of the bladder. It is eom|)otMMl uf a 
mucous, musc'ular, and vascular coat. About oue-ei^4ith of 
an inch within the meatus are the o|^iJtngs of two tubular 
glands, ju(*t large enough to admit a No. 1 prol)euf'the French 
ecide. These plandiilar lubuh-s run jmnillel with the long 
axis of till* urellini. iH^ueatii the mucous membrane, in the 
inurii'uhir wail. They vary from three-eighths to three-fourtiis 
of ail iuch iu length. 

Tni-: Hymkn is a cref^centic-shaped fold of mucous mem- 
brane wh(.H»e convex Ijonler is attached to and continuous with 
the |x>sterior wall of the vajfiual orifice, just inside the four- 
chetle. lis sides then ruu upward to terminate in the horns of 
the crescent, which hist are united by its anterior ctmcave 
iMirtler. It varies in form in ditfrrent women. Sometimes 
the horns of the crescent, iiifit^^nd of comiu;; to a [»oint, are 
continued ns h narrow band to the anterior vaginnl wall. 
where the ends join each other, leaving a circular or oval 
0]>ening in the centre ("annular hymen*'). Occasionally it 
covers tiie orifice of t he vagi tui entirely ( " impf-rJoraU 
hymen '*), or it may present a number of very small 0|H»ninjr8 
(** (Tibrif(tn)i htnneii "). It also vnries in thickness and streu^h. 
It is usually ruptured by the first act of voifui*, thoujrh not 
always, and nuiy l)e torn by other causein, s<* that it is by no 
means so sure a sign of •* virginity " as was fbniierly sup|»o9ed. 
Sometimes the inner border of the hymen has a fringed ajv 
[>earance, re^enihling the entl of a Fallopian IuIkj (hence 
called •* hynicit firnlirialus" ) : this might be mistaken for a 
normally ruptured hymeu- Moreover, it is sometimes abseut 
altogether. 

TiteMyrtifokm Caruncles (CARinfruL^MYKTiFORMEs), 
— F(»rmerly these were said to be shrivelled, projecting remains 



THE VAGINA. 43 

of the ruptured hymen ; subsequently they were considered to 
be vascular» menibrauous prominences placed immediately 
behind the hymen, and quite independent of it More recently 
they have been ascribed to childbirth, pressure of the child's 
head during labor causing necrasis and sloughing of tiie pre- 
viously torn hymen, of which, therefore, these so-c^alled carun- 
cles are the only visible remains. This last view is prol)ably 
correct, and explains why the caruncles are often absent 



CHAPTER IV. 

INTERNAL ORGANS OF GENERATION. 

The Internal Organs of Generation are the vagina, 
uterus, Fallopian tubes, and ovaries. 

The Vagina is a membranous canal extending from the 
vulva to the uterus, hence sometimes called the "vulvo- 
uterine canal." 

It is made up of a mucous membrane (covered with pave- 
ment epithelium) continuous with that of the vulva and uterus. 
Outside the mucous coat is a thin, muscular layer continuous 
with the uterine muscles, whose fibres run, some longitudinally, 
some in a circular direction, and others obliquely. The mus- 
cular coat becomes thicker during pregnancy. It is extremely 
vascular, its vessels l)eing so disiwsed as to constitute an erec- 
tile tissue, esiMjcinlly toward the vulva. Cellular and fibrous 
tissues also enter into the composition of the vaginal wall. 

Underneath the epithelium of the mucous membrane are a 
large number of vawular papillae. Along the median line of 
the anterior and jwsterior vaginal walls there is a vertical 
ridge in the mucous membrane (the *' anterior and posterior 
columns" of the vagina), and diverging from these, laterally, 
the mucous c(mt is thrown into transverse ridges which admit 
of dilatation of the canal during lal>or. 

Its posterior wall is about three and a half inches long, its 
anterior wall about three inches. Its diameter is a little above 



44 



IHTHRSAL OHQASS OF QBNERATWIf. 



an iuf'h. At re-st^ the nntcru»r ami |y»!!terior wnUt^ are in con- 
iiiri witli eiich othor. 

Witli regnnl to tlie exact silnation and dirwiioM of the 
vagina, the (lesTcriptinnH ainl illustrative plate?* (tf anatoiiiistfi 
diHer witlely, Uoujrhly >*|)eakin)jr, uocur«ling to l^Lshiiiau, 
"it lies in tlip axis of tlie [lelvin, Imt iL< axjs t^ pliured ante- 
rior to the pelvic outlet, ao that its lower portiaa k curved 
for\yanl/' 

Its attaehinerite to adjoiuing organs are q& follows: the 
posterior wall is eotiuedeil hv its m'uUUr three-fifth)* with the 
reetuiM. the united wally (•on^•lituli^;^ the re<*t(>-vaj:iiial Keplum ; 
ittt town- fifth ii* se|Mirated troni the reetuni, and is iti omiaet 
with the |K'riiieal body ; while it.s upfter fifth ii» in eoiitaet with 
the told of iK-ritoneuni whieh di-weends Itehiml the ivoitd) to 
form nunt^las's nil-dr-Hor. \t:i anteri(»r wall in unitetl liy eon- 
neetive tisane with the |M»iterior walla of the Madder utid iiro- 
thra, ronstituting, nv|»ectively, the vesieo-vaginal and urelhro- 
vajcinal !*epta. (See Fig. 7, paj^e 55.) 

The upfter extremity of the va^i^aI cylinder surrounds and 
is atlJU'hed to tlie neck of the uterUH: it is ealliNl i\w.ftiruu. 

On earh :?ide of tlio orifice of the va|;iim are the httfhi irMit" 
hull already de.'**TihHl. Iiumediately l>enejith and iKdiind the 
|Kwterior rouml extremity of thin hulh of the v<«til)nle is 
plaroi], on eac'h sitle, the t*nh*t>-vafjliift! fj/anri fanalogvie of 
('ow|)er'8 glan<l in the n»ale^ and variously calhvl the )fland 
of Hu;ruier and of Bartholin). It is a con^rlonierute pland, 
varying in .**!•«» from a horse-(>ean to an almond, and secretes, 
dnrin;; dexual excitement, an excee<lin;rly viwid nuicn.s whitrh 
is dii*chargeil from the orifice of the gland-duct into the fosisa 
mivi<Mdari». 

The vagina is nhnndanlly supplied with nerves, e»(»ecially 
towanl its oriiice. where it is endoweil with a [Hvuliar senai- 
hility. Iti* arterial supply in derived frttm the uterine, hy|HH 
gastric. veriical, and pu^lenihil arteries; and it>* pumer*>U3 
venouH plexii#t*s, (-ontinuous with thoa* of the vulva, clitoris, 
and utern-s terminate in the hy|w>ga8trie veins. The vaginal 
veins have no valvee^ 



The L^TKurs i;* a thick-walled hollow onran, in the form 
of a truncatwl c<>ne. slightly Hatteued auten>-j)osteriorly, «itu- 
ateil in the mi<ldle of the |>el\ne (mvity. its npi^er end l>eing a 



THE VTERVS, 

FlO. 7. 




little below ihf plniit' of llir I'lqienor nlrnil. Tlir MmMiT in 
iu trout of it, tilt; rcctuui hehiiid, anil the vujJiiiJO Iwlow it. 



46 



INTERNAL ORGANS OF GENERATION. 



The smnll intestine rests U|xm it from above. It ha* three 
r/Hittt: fl] u ferou.H coat (f)eriix»neinn ) on the oiilsiilc ; (2) a 
nuis^.nilar cont, which Ziyi's tliiokncjv nn<l w)li<iilv to the 
uterine wnllri, nnti is (*oni|Ki?;e<l of iiofii-stritilt'^t niusctihtr fibres 
arrange*! in layers, having flirt'erent directionb, cinnihirly, 
loii^itnilinally, mitl i*|>imlly, whieh are closely adherent to 
and decuasute with each other ; (3) a nnicouy lining continuous 
with that of the vniLrinH and Fallo])ian lubes, and covered with 
ciliated, e(dnmnar e[iilhfriimi. When a new nuicous mem- 
brane begint* to Conn in the nleru.'* after nien^'truatioti the cells 
are ivifhout cilia ; but the mature celln nrr cilialed, which 
accounts lor some oli^rvers aeserling that theee cells are cili- 
ated and others that they are not, 

That (lortion of the nock of the uterus which proje<'t» into 
the lup Iff llie VJiijina in covered externally with |iavenient 
epithelium. This last joins the e<^ll^nnar epilhclinni of the 
iuterior of the uteruH jn*-t within the external os uteri. 

In Um^nh (counting the thirkne**** of lis up])er wall) it is 
frou;.'hly ) ultout 3 inche>! ; the lenf;th of itti furr'/y, from the 
external o8 to the top of the fundus (not in<'ludin^ thickness 
of upper wall), is *2^ inches; its widih, transversely across its 
widest upi^er part, is H inchi* ; aud its ^'realest autero-posterior 
thickne** 1 inch. At the end of i)re^nancy it attains the size 
of a foot or mere in le[>;;th, and H or 10 inches tnuisverbely. 

It is divide«l by aualomtsiB into fundus, body, hod neck. 
The fnttdtiji is all that rouinleii jwrtinu placed above a hori- 
zoutal line drawn throuijh the anodes where the Fallo]tinn 
tubes oi>en into the wond) ; the />w/v is all that portion betv\ceu 
the fundus and the iie<k ; and the mck is all that jiart below 
a line drawn horizontally through the organ at the level of 
the internal rts uteri. 

Its cjjvit}' is divided into the cavity of the bndy and llie 
(•rtvily of the neck. That of the luMly is trianjrular auil flat- 
tene<l anlen>j)osieriorlv ; it bus throe i»|>enin;j:s. th(»se o\' tlie 
two Fallopian lubes above and that of the us internum below. 
The cavity of the ne<*k is barrel-sha|»e<i or fusiform, and com- 
paratively narrow ; it is constricti'd aliovc by the interna! os, 
that s*'parates it fn»m the cavity "f the Iw^dy. and ^nnvs nar- 
n»w ajjrain at its ternnnation in the external os uteri. Ailer 
ehiblbirth the rtaistrictions of the internal and external os are 
less DUirkei]. (.See Figs. M and 9, |>age 47.) 



STRUCTURE OF UTERINE ATUCOUS MEMBRANE. 47 
Fro. a 




Section oflheutenii before childhlrtb. a. Cnvity of cervix, c Carltjofbody. 
c. Oi lnt«raum. t. Uterine wftll. (Frum Hitt:iRS, aflvr Tahhikb.) 



ria.». 





BecUon of ulonis Bflcr chlMbirth. The letters have ihe wme mettning (u. in 
¥\g. S (KniMi Rakskn. liner Takmeb.) 



MiCROsroPK' 8TRi:<-nTRE of the Utkrine Mucovr Mkm- 
RRANK. — It is <v)m|w»RMl of nmnms follirlrs {** utrinilnr 
i;laMil«'') plucetl |?er|)eii(liculurly tu tlie inU-nuil surfuce of ihe 



48 



iXVERS.iL ORG ASS OF iiESKHATlOS. 



wumi). Thfir inoiitlm u{>eu iuU> the uteriue cavity, uud ibey 
terminnte by rouDtletl, bullx)Ui» extreuiities (some of wliicL are 
hifun-utwi) iijkhi the inui^culur wmt The follifles are lined 
witli <*(iliiiiiiK)r (Epithelium ; au<l ttoiiie iilea muy lic lorme^l of 
their nize f]i'flth »f a liuf in diameter) l»y remeniltering that 
there ure ul>out teu thuuniud of them iu the niucouH membruue 
of the cavity of the iteck alone. 



Broad Lhjamknts ok the Uteris, — These are 



Mm 



ply 



folda of peritoneum eovering the external surfm-e of the 
wODih. I^t \\& imagine a line drawn arroi^t the outnide of the 
top of the fundus and prolon(j:e<l transvcrwdy until it reJW'h 
the HJdei} of the pelvit*. Beginning at tlii^ irnaginur}' line a 
bruiul layer of |>eritoneum |>ii»»es ilown over the uiitr'rior wall 
of the womb to the level nf a [Htint midway l>etween the inter- 
nal and external ot«, when it tuni:^ up and is reHected over the 
posterior wall of the bladder: thi;* is the anterior liroad liga- 
ment, A similar fold |«ish'h di»wu over the |Mifterior wall of 
the womb, going low enough to cover the upt>er oue-tif\h of 
the poHterior ttifjiimf wall (at> already explainitl), when it 
turns up and is rettecteil over tlie anterior wall of the rectum : 
tbifl is the pfmterior broad ligament- Thus the nteniH, with 
(and lietween) its two bn)ad ligumenlH, forms a nirt nf Irane- 
vcrse partition to the |X!lvie cavity ; the bliulder, urethra, etc, 
|}eing in the front eomjHirtMient, atid the rei'tuni in the back 
one. The lateral borders of this douMc ligamentous curtain 
are attiiched to the sidert of the pelvic and iienee tlicK^ liga- 
menlif are noiiielimes Ciilled "right*' and "lell," insteaid of 
" anterior" and "posterior," x\» al»ove. 

OriiKK Lh;amkntr ok tiik LTtkruh : 

Fir^t The round Hyamt'ttts, which are fibro-www^i/Air ctinla, 
4J inches long. They begin near the Hujtcrior angles of the 
wonib» and pai« between the two fohli? of the broad ligament>s 
«mxv!<sively oulwanl, forward, and then inward, to llu- inter- 
nal inguinal ring, and through the inguinal 4'anal, their U't- 
minal tiltre?* being l'K*t in tiie wtms ittifrlit atnt /ahltt majtmi. 

Second, The lYMinhnftrint' ligaments : seniilumir-shii|M>i] 
folils of |ieriUnieum passing from the hjwer part of the biwly 
of the uterus to the fundus of the bladder. 

Thinl. The utfrthimrrui ligameuts : rreKrentic-sha|»e<l fohh* 



I 




50 



ISTJ'SHyAL OBOASS OF QEyERATlON, 



one iuch in length, ami is ^leil the uicnMivarian ligament — - 

sometimes the " /f'/'/mrHf «/ f/if oiwry/* All the ligiiuients of 
tho 1IUTU.S foiitiiin wmie mustnilar tissue, which is iucrcaawl 
during' j)rey:iiaiic)'. (See Fig. H), page 41*.) 

The rehuive |x»sitiun of the uU-ru.^ and ilB lignmeiiLs with 
adjacent orgiuui, w beu seeu froDi above, i& showu iu Fig. 1 1. 



riu. u. 




Grnerative orxansiecn from alxivt'. m. Tu^ici. a. a. (In front.) Remainder 
of hyi*o(fiistric nrtciltfR, a. a. (Ik-blrHl.) SiH-ruiBtlc vt'HiieU iin*! nerves. B. 
Bladder L, L Ruiniil lf)tAii)fiiI<i. i'. Fundus utori. t. t. Kallnpiun tubes, o, a 
OTAhi's. R- Kectum. o. ICIehl urutvr rcfttlnit on the iwtjiia musrk. o. riero- 
Mcnt lignmenu. t. Lut lumbar rertebm. 



Artkrikh of the Womb. — The uterine artery (one oii each 
ride) is given otrfroni th<' nntorior l»ranch of the infernal iliac. 
It ih*iioeniJs litfiiiii] the jK-ritimi^Ttni to tlir fornix vnLriim', where 
iu |iiiisili*in iiiay he t'eli with itie fiiiirer dnritig prcgnanrv, and 
then ascemls hctween iho aniftinr and jMisti-rior fnlds of the 
broad liiranu-nl. along the nide nf ilu- ecrvix iind niriniji uteri 
ftu IkjIIi III' wliich it pvef* oH' many (h'eply iient'trating 
braneh<*], and, finally, its nniin trunk becomes directly con- 
tinuous with the ovarian artery. 

The orvirmi* artery (one on each sidis eorresponciing with the 
gj)ennatir artery of the male) is given otf from the aorta 





I 



VEiyS OF THE UTKRVS. 



51 



incbesi above its bifurcation. It descends into the pelvic cavity, 
and then ascendH between the two folds of the broad lignment 
to the Fallopian tul>e, ovary, and fundiw uteri, and terminates 
by annstomoMs with the uterine nrtery just dewril>c<l. 

At the junction of the Iwdy aud cervix uteri is a circumflex 
branch which unites the arteries of the two Hide*i, and which, 
when cut during Mur«;ii*ul o|H.'ralions, bleeds profusely. The 
arterial branchi's in ihe uterine walls are remarkable lor their 
Dumeroufi auai^tomoBes and Hpiral course (hence called helicine 



Via. 12. 



ANASTOMOSIS OP 

UTtRINC AND 
OVARIAN ARTCRICB 
Mri,iciNE SRANCHLS 




FALLOPIAN 



IRIAN ** 
lOUNO LIOAMCNT 



VAGINAL VCNOUS PLCKU* 



UNCTKM 



TCRINC ARTCflT 



SUPERIOR VAGINAL 
ARTCRICS 



OS UTCRt WAGINA CUT OPCN SCHIND 

Blood lupply or uterus. (After TcfiTtrr.) 

arterui*), the latter f|inilirv providing — it i.« supposed — for their 
longitudinal exten.^ion during pregnancy, a sup|>o8ition that is 
very inHterially weHkenwJ by the fact (hut I he arteries are more 
tortunns diirinp pregnaney than In'fore. MorcHJver, the arteries 
of ihf uvary |)resent the jianie spiral course. 



Veinb of the Uterits. — These bejrin by small branches 
continiiouEt with the fine plexus nf capillaries into whieh the 
uterine arieric* divitle in the internal lining of the organ, and, 




52 ISTEIiXAL ORGANS OF OEyERATWy. 

iD08culatinpr freely \\\x\\ each othert uuite to form larger veins 
(always wlfhunl valves) iu the Mjlistaure of the uterine wall, 
whence tliey eventually pa*« out lowanl the folils «f broad 
ligament^ where, joinini^ the ovarian and va^^ual veina. a re- 
markable venous network 'm*. fonneil, known as the *^ jtovipi^ii- 
form ///e'^im." (See Kijr. 12. page ol.) ()u each eide of the 
uterus, near it>« junction with the lop of the vngina, the greater 
nutnber of vesH.*lH in (hi(< plexutt \in\r their bhKMl into a trunk 
of considerable rfize — the inteniai »|>erniatic vein — which cn)fH 
ties on the right ^side into the venu cava and on the letl into the 
lell renal vein. 

Nkrvis. — The ncn'ous supply of the uterus is received 
chiefly from the ."yniputhctic py^teni — viz., from the hypogas- 
tric, renal, f|)ermalir, and aortic plexUKt*. 

There ii* no longer any tloubl that it alwj receive** branches 
from the cerebro-spinul Hysteni, ilerived chiefly fn)m the second, 
third, and fourth Ku>ral nerves. During pregnancy the nen'e- 
tihres increase iu size. 

Lymph ATics. — The wond> is abundantly supplied with 
lyrtiphat)(>s and ilh lynipalhic vc)«cls terminate in the pelvic 
an4l lumbar glandK. Il i.« chiefly through th«*e lyntphatic 
channels that septic nintlcrs are taken up frt»m tlio i*avitie8 of 
the ulerua and vagina, tniuspDrlcd to ullier organs, aud carried 
into the blo<Kl, thus producing ^^pticicniia. 

FuxcTioye of the I'TEKri*. — It \^ the source of the men- 
strua] discharge ; it ree/'ives spi-rnialic fluid from the male 
and the germ-cell — whi-lher inipregnal<«l or not^from the 
female; it provides a jtlace for the fo'tus during its develop- 
ment, and is the ^Mmnv of ilr* Tuitritive r-upply ; an<l it contracts 
at fidl term to ex|fel tlie child. 

During gt^tation »/// ifit^ lissucs of the uterus undergo a 
decided phpiologicnl hyfn:rfrt>jtftif. After (Jelivcry they go 
through a sort of gradual pbysitihjgical atruphi/ — back again 
to what they were Ix'tore conception. The enlarge<l nui^cles. 
especinllv un<lergo tatty «h'gpiicnilioi) aud al>s<irption — callefl 
** ituHthitiinu'* \\\ Cfmtradistinctioii to **n'otution" or develop- 
ment. The pnicess of inviiluijon aMjuires a month or six weeks 
lor its completion, »»metime« longer. 



■ 




FALLOPIAN TUBES. 53 

MoBiLiTT OF THE UxKRUs. — The woiiil) ill its tiormni con- 
dition is not fixed or adherent to iiiiy part of the skeleton, hut 
enjoys coneiderahle nihility ; it is 8inii)ly su8pende<i or hung 
in the pelvic cavity hy the t(!nt-like aprons of |)eritoneuni and 
other ligaments attached to it, as well as hy its nerves, hlood- 
veasels, and vaginal attachments. A full hladder pushes it 
backward ; a distended rectum forward. It changes its posi- 
tion, by gravity, as the female changes her posture. Viewed 
through a speculum, the vaginal part of its cervix may be seen 
to rise and fall with every motion of the diaphragm during 
respiration — an observation becoming still more apparent 
during the violent diaphragmatic motions that attend laughing, 
coughing, etc. Forcible injection of the uterine arteries afler 
death causes the uterus to rise in the pelvis and execute a 
movement resembling that performed by the penis during erec- 
tion, which leads to the supposition — difficult of proof— that 
this actually takes place during life under venereal excitement 

Fallopian Turks. — Given off from the uterus, at each of 
its superior angles, is a tube whose canal is continuous with the 
uterine cavity. These are the Fallopian tubes (sometimes 
called "oviducts"). 

Each tul)e is about four inches long ; near the uterus its 
diameter (^ of an inch) will just admit a bristle, but increases 
in size in its course from the womb toward the free distal end 
of the tube, where it is as large as a goose-quill. The tube 
})asses from the uterus in a somewhat tortuous course, between 
the folds and along the up|)er margin of the broad ligament, 
toward the side of the pelvis, and terminates in a dilated, 
trumpet-shapeil extremity, the free marjrin of which is, as it 
were, fraye«l out into a numl>er of fringe-like processes calle<l 
"fimbriae;" one of these, longer than the rest, is attache<l to 
the outer extremity of the ovary. S>me of the fringed pro- 
cesses are continued as thin, leaf-like, longitudinal folds of 
mucous membrane into the dilated end of the tidn?, which 
grow narrower as they approach its uterine end, as shown in 
Fig. 13, page 54. 

liike the uterus, the Fallopian tubes are conipos(»d of three 
coats: 1. A tteroiti* (peritoneal) coat on the outside ; 2. A vhia- 
(Tw/ar coat amijiosed of two layers, vi/., circular fibres (inter- 
nally) and longitudinal ones (externally) ; -l, A mucous coat 



64 



jyriCBSAL ORGANS OF GENKHATIOK 



coiilintioiLs \vi(h tlint of the uterufl ami lined with oiliateil, col- 
uriDiiir (•[tilhfliuiii. At llii* distul vw\ ot* the tiilio (he iiiuei>us 
cuaC lA conthiiiituK with tlte [lerilnrieiitii, uihI turnUht^ the only 




Tho ovary and ovldnct. 1, 1. Ovary. 2, t Part of uterus. 3. Ovarian liga^ 
mciit 4. 4. Oviduct, Us wall opened by a lotij^itudlnal Iiictiiloii lu iihovr the 
lon^tudfnal fuldiiorits lining mombranc. f>, 6. Pavilion, rrum lati:rnal aur- 
dM-e. 6. 6. Fimbria atutchod to the ovary or tubo-ovari»n llgamcuL 7, 7. 
Ix>ngitud(nal Tolds. ft. IntcniKl end or Ibo ovfdiirt. 



instance in the body Vr'here a 6enni« uinl 
are thus joined. 



a tmuiJus nienibraoe 



FuNmoNB OP TBE Fallopian Ttbe. — It rtmveyp sper- 
matic tluiil t'nmi the uterus to the ovary aiitl (mhuIir'Is tlie 
jjernwell fn>ni tho ovnry to the uterus. When the ovule 
(pern)-*'ell ) is ulmnt to Ix^ di«'.har»red from the ovisnr, the Wm- 
briie t>t' the tnln? trnipj* the ovary. »j as to promote the «afe 
entranee of the din»iiiiirive ^erm-ooll into the trum[«_'t-iihaped 
nionlli oftlie lulie, i^lieiieeit ift conveyed, hy ]>eriii{nltie motion 
of the eniial, into (lie uterus; tiiit* trnnt*niis?ioii ot' the penn is 
al«j Hivisted by the eilia oi'lhe e|iitheliiKn, wliich wave townni 
the womb. Tlie waving: of the eilin is said also to |>roduee a 
current, towar<] the tul)e, nC ilu- llnid mveriii}^^ the inner sur- 
face of the periloiieiini near the llmbriiUeii entrniice. sr» that 
the ovule, when not at onoe receive*! by ilie iiilie, may |ui>?sively 
float into it afterward \\]>'u\ tliis nioviny; fluid. 




THE OVARIES. 



55 



The Ovaries. — They are two in uumber (rarely three), 
and are placed one on each side of the womb, behind and 
below the Fallopian tube:^ Formerly they were thought to 
be situated between the anterior and posterior folds of the 
broad ligament This is incorrect. The ovary is really set 
"in a hole in the posterior layer of the broad ligament, as a 
diamond is fastened to a ring.'' The part projecting poste- 
riorly, above and beyond the surrounding margin of broad 
ligament (as the diamond projects above its setting of gold), 

FiO. 14. 




Relations of ovary wilh utonis and Fallopian tulx'. The two lines incIoBf a 
V-sbapcd bit of the ovary, which is represented, largely magnified, in the next 
figure. Both figures are. of course, diagrammatic. 

is therefore devoid of any jxTitoneal covering, the free surface 
thus expo8e<l Wm^ the colunmnr e|>ithelial layer of the ovary 
itself, as shown in Fij;, 13, pa^'c 54, where a distinct line indi- 
cates the transition from perit^meum to ovarian e|)ithelium.' 
The ovary is a]»)>roxin>at('ly almoiul-shaped. hence it has two 
ends, one of which is connected with the an^de of the uterus by 

' In Fig. 13 the whole ovary is representfd pushed up out of place. If pushed 
down again to Us normal fM)sition, it would tw M(nv the Fallopian tuln*. as 
shown diaKranimatieally in Fig. \i. 



r>6 



ISTFMNAL ORGANS OF OESERATfON. 



the ni>ro-miiM*ul»r " lijrnment <»f tlw ovarv,'* whil<» the ollu^r is 
jniiieil to ih«' tniin|K'l-sli:»|H<l ornl oftho Knll(t|ii)iii tiil«' l»v one 
of the ])roliMiL:i*<l Hiiiliriii, kiinwii iis tin* liilMMJvnrinii li^iiiiieiiU 
or fimfiiin itiuii'ii'tL Thr ovuriaii liIt«Mlvcsi*rl-'* pass up iK'Uveen 
the* tsvo fdhJfi of [frt)a<l li^'aiiifiit ami ftitvr ihr orpin in ii littto 
(leprtWion calU^I the hilum, l!aeh ovary in iiUiut niw \ucU and 
a hair in leii^h. thn?t*H|uartei> oi* nn iurh witlti, and <ine-th)r«l 
of an iiirh thick. WtMjjht, one ur two Jraohius. 

Its ftturfi"ii is oviibition — ihat Ih to nny. the pro()uctioa« 
(levelopiiK'nt. niaturalion, an<l discharge of ovulws. Heuce 




Tr[an;;ii1iir t>iCf>rorftrian Rtrfiinnrnt Trnm ni'tiry, Mof^lfttMl tOflli(»w (irnftBan 
rollicule ami dviile. I, KiilDiotU) mvorlnt; nf (ivsry -.' Tnnica Rlltnunu'a 
<nt>rQiU). 3.3 IMniTcnl r>aru of stroma. 4. liniafinn follicle? (litniiJi nhmsA). 
5. CJraanati vi^Irle ur mvIsac. 0, fi, Tuniru tminolf>*«ii. 7. Lti|uor rollfnill. 
8. Vllellliit; nirmliranc, «r iu>nft poUu(~Jilft. 3. (imniiUr vltullwf. nr yulk. 
10. Ocmitniil veilfle. II. Oerniinul ttftot. 



the ovaries are the e»K>ntia1 <»rgan9 of generation iu the female, 
an the NvlirK-j* arc in the niah'. ( Fitr. 1 (, ihil'o .'►.')» nhows rcla- 
lioiw of ovary wilh nlt*rii>* ami Falhipian luUc. A trian^rtilar 
hit of f»varian Htnuim, nhowin^ ovuiii iim;^iiilii.^l, \» .seen iti 

Fig. ir..) 



STRUCTURE OF THE OVARY. 57 

Structure op the Ovary. — The ovary is covered exter- 
nally with a layer of columnar epithelium, the cells being like 
thoee lining the Fallopian tube, except that the ovarian epithe- 
lium is wiciliateii. This surface-epithelium is sometimes calle<l 
"germinal epithelium," since some of its cells become, during 
foetal life, deeply embeckied Iwlow the surface, in the solid 
substance of the ovary, and thus constitute ovules. 

Immediately beneath the external covering of epithelium 
is a thick coat of white, fibrous tissue, the iuni^ia aihuginea. 
Inside this last we find the solid substance of the ovarian body 
(the kernel of the ovarian nut, so to si>eak) — the stroma — 
composed for the most part of fibrous and muscular tissue, and 
traversed by numerous bloodvessels. 

Dotted about in various parts of the stroma are little, round 
cavities, called " Graafian /o/Zw/e*." The wall of these globu- 
lar follicular cavities is made up of the stroma substance itself, 
being in fact composed of a dense layer of the stroma's con- 
nective or fibrous tissue, and is therefore sometimes called 
** tunica Jibrom," It is immediately surrounded on all parts 
of its periphery with an elaborate network of capillary blood- 
vessels. Fitting close inside and completely filling the 
"Graafian follicle" is the "Graafian veMcle" or "ovisac,** 
sometimes termed, in contradistinction to the tunica fibrosa, the 
*^ tunica propria," Loosely adherent to the inside of the ovisac 
all around is a granular layer of epithelial cells, the " tunica 
granulosa," Inside this is the *' li^j^ior foUiculi" (or fluid con- 
tents of the ovisac), in whi(;h floats the human egg, or ovule. 
It is only a yolk ; there is no white to it, so that the next 
membrane we have to encounter is the zona pelludda, or 
external membrane of the egg, while next inside of this is the 
internal or Hfellitte vuinbrane ; l)etween these two is a little 
space occupie<l by a fluid, called the peri-vitelline spare. The 
eg^ embrat-ed by the internal or vitelline mombrniie floats in 
the fluid of the ]^ri-vitelliiie space within the zona j>elluoida. 
£mbedde<] in the sulistaiice of the yolk is the " gf-rmiunl 
vesicle^" ami inside (hat the ** germinal sjmt.*^ Besides the 
tunioA granulosji covering the inMde of the ovisac, a reflecttsl 
layer of it is (lis|K).«tMl all around the nuWtde of the zona |)ellu- 
cida. At l)irth it is said each human ovary really ctmtains 
about 3(*,(M)() (inuifian follicles, with their contents; but only 
the few that are approaching maturity are large enough to l>e 



68 



INTERS A L OROJyS OF OKNHRATl02i. 



Been with the imkin] eye. The ovules are thorefore forme*!, for 
the tti(Hi| parU l^efore liirth, though their iurnmtiim Ls thought 
to fontitiiH' in w»iiut iiistanr-wi two op lliree ytttts Inter. Early 
in tivlal lite (he " [iriinonliul ova" wen* Hiiipiy enlur^^exl epi- 
theliutn ct'lls — jrerin epithelium — upon the external aurfae« of 
the ovary. The way in wliifh llu-y iHtotni-, later on, b^olated 
ovules hurie«I in (he ovariun stroma, i* as I'ollowis: (.'ylimlrunl 
intleetioiiK ol" the epithelial eoverin^ of the ovary turn in and 
<lip ilown into the snl.statice of the litrouia, formiup a sort of 
liihule (like the follicle of a tmiicou^ meiiibranej. The hegin- 



Fio. 16. 










M' -'*.'*' 



Vertical Beciion ihrtu^h ovary oriuiman neliiM. a, g. Ucrm cptthellum. with 
«, o. dcveloplnjt uvutea in il. «, ». Ovarinn »t.rt)tna rrtTilnininsr, r, ftiBifnrm con- 
nccttve-ttMiiie rurptmolci. u. i* ('Apillnry hlooitvosiu'l!!. In Ihc reiilrv dF iippur 
BUrfnov of n»ciire «n Invulutioa nf the K^rm cpllhellum Ib shown : and at Oie 
luwet left wXAv an Isnlulvd primonllal ovule, wlih coaaectlve-tlssiie oella ratifi- 
ing thcniai'lVHi round it. (From PLArrAiR, afler FouLis-l 

ninjr of «ueh a folding-in of the germinal cpitheliutn is phown 
in Fi^. IB. 

While these inflertionfi of (rerminiil epitbeUuiJi flip down 
int(* the ovarinn Htninni. the ronnerlive tissue of the stroma 
itself j^nw** up arouin! them, anil finally unilt-.s fiittinjr otf the 
nwks of tlie tnhulew. ami thut< hiiryin«» iheTii \\\ the pultstanee 
of the ovary, where (hey lien)me ovisaes. The several stages 
of the priN't^sH are siiown in V'\<i. 17, pJijre 5i*. 

The way in whieh the ovule (e;.'ir, ^reniM'ell ) t:et« out of the 
ovary is a** folhtws: A:* the (tnuilian tollirlt* rearhe.^ nialnrity 



J 



THE CORPUS LUTEUM. 



59 



it approaches the surface aud begii)s to cause a protuI)eranc« 
(like a little boil) upon the outsi<ie of the ovary. Eventually 
the epithelial external coat, the tunica albuginea, the wall of 
the Graafian follicle (tunica fibrosa), and the wall of the 
Graafian vesicle (or ovisac), all burst at the same ]>oint, and 
out comes the vitelline membrane, safe and whole, with its 



Fio. 17. 
pa KE PS 




K4, Fi M}> K 

Section through part of a mamnmlian ovary (aflor Wikdkkshkim). KK. (ier- 
minal epitheUum. PS. Inflected surfuee of epitlu-Umn. fonniiif; tnlmle or i^rk- 
cord. U. Primitive ova. (J. Investing cells. A'. Cermhial vosicU;. S. FoHIp- 
ular cavity ariHJiig in one of the older follicloa. //. Folliculttr cavity more 
enlarged. Ei. Nearly inatiirc ovum which !ias developed around it the zona 
pclluclda. Mp. Mg. MembranH uranulosa. />. I'roligeroun disk. So. Ovarian 
stroma, ly. (Jraaliaii follicle, g. It I ood vessels. 



contentfl, and olinfrinj? around it a loosie, irrcjrular inas.s (»f tlic 
"tunica ^ranulowi," called tl»o '^pron^rroui* dittk." 

At the moment of rupture of the iollicU\ or shortly aiU'r- 
ward, the ovule is received by the Fallopian tube nn<l c»in- 
veyed to the uterun. 



The CoRiHTri Li;tkl'M. — After discharge of tlu^ ovule, 



60 



INTERNAL ORGANS OF GENERATION. 



Wgelber with the Iit]Uor folliciili and that pert of the tunica 

^runiilrisa <'linLnr;j' U> the ovule, the empty, tle:*cTii'«l oviNic 
iiWt^ U|) whU n rlit] of IiKhmI. Ui whicli iire suiv^-(|ueiilly nddeil 
newlv [iroliicruU-^l ct'lh ui" ihe ineinhnuia jL^niuulus;! ; wumler- 
in^; wliiu^ {-oriiuwles i'roni tin* liloixl ; and a '* vitelluH-like 
HuliHtam't^ " uf a jfrftow colur coiilaiiiiuLr ^ninuK« and globules 
re^'nihlin)^ thoHt^ of the vilelhiH. Tlie uhit« ItliMxU'orpu^'les 
accumuhitiu;: near tlie wait of the vt't'icle prtv;^ the reumiuing 
c<>ntenti4 toward the centre of tlie eaWtr, while vaseular 
j>a|)illtL' prujert on all sidee toward the (Hintro. The larger 
vc-i^i^U indenting the yellow xaam impart to \l6 exterior a 

Fia 18. 




Section or nvary, tihowlng norpus lutfiura thrw weeks nher mcnBtraatlcm. 
(After Dai.to>.^ 



ibldeil appeaninee, formerly a»acril>ed to convolutions in the 
wall of the ovisac. Evontuully tht contents of the «ir are 
aiit«irlHHl, and tlu- fullicU' shrivel.^ and contract*; into an iumg- 
nifioant cicatrix or *liniple. The yellow c<ilor of the tvjnleuts 
of the ovitfac hni* cnuHMl ihe site of the difschargwl ovule to be 
ealletl ''corpUH luttniin" — yellow b««ly. ('or|jora lutea are 
nf two kiink "true" and "fnlne." If the ovule l>f imprt^- 
uated. a tru/' ntrputi luleuni la dcvclo|H*il ; if iinprepmtion 
have not taken place, there re**ultd a ;«/*■; corpus luteuni. The 
iMiei'iid (chief j diHl'renct** lK*twwn the two an* at* folh)WH : IsL 
The false o^rpui* luteuin increases in siz*' for threes weeksotdy ("see 
Fig. 18j ; the true one eoutiuues to grow fur about Iburmuntba 



THE PAUOVARIUM. 



61 



(get* Fip. If)). 2*1. After three weeks the fnlpe corpus hiteuin 
<le<'line=* rnpidlr iu size, ami U redurwl lo a oicatririal ilinijfle 
at ihe emi of two tiioiithH ; while the true one, havinjf grt^wn 
«> larjre n* to oc<*U|>y the ^v^atov |Mirt of the ovary by the 
fourth (tr lifth month, renmiiifl about the Karne size duriujr the 
tifth Hiid sixth months then f^radually iltxlimv iliiriii^' the 
peventii. eiifhth, and ninth months; hut it is not reduced to an 
iDi*i(ruiHfant ticalrix until one *»r two uionthii; aiU-r delivery. 
3<l. A true i-orpns Inteuni iit single; a false one will lx» aeetan- 
[xinieil (either in the san»e or the o|t|K)Mte ovary) hy the vij*i- 
bly evident remains of its predeceteor. 4th. Tlie cicatrix 



Flu. lU 



■lO. 20. 




C<>rpaB lut«Ufn *-*f ihr fonrtti rmnth of prcg- 
ttuncy. (Artcr Uai.t»jN ) 



Corpus lutenm nf pmmoncjr 
At UTm. {After Daltwn.) 



refttihinK from a true roq>iis luteunt is more diBtinctly Btol!at« 
than the eiontrix of a false one. 



TliK Pauovarii'M faonietimet' (^IKmI the "tirjfan of Ko^n- 
muller'*). — It ip ihr remains of the Wolffian fiotltf of foetal life, 
and eorrpH|Ha)dt< to ilie e|iidi(lymis of the male. Plaeed in th(* 
fMisliTiiir ln|d of tfte hroad liptmenl, where il may Ih* seen hy 
holding' up the hitler and |(>okin>r ihrnutfh it hy iransmilteil 
li^-hL. it e»)nsis(s mI' from len to twenty torttmus tuU-s arr:ni^e*l 
in n |)vranndal form (like ihe rih.-4 of n Ian), the hoM.* of the 
pyramid, »nnnounte<l hy a tranHvi'n^ tul>e with whieh the 



62 



INTERS A L OROASS OF OENER.iTiON. 



others commiiniciiUv \mi\fs toward the Fallopian tulH% its a.\iex 
lout oil the Piirfawi of the »ivary. The piin»vJirium has no 
excretory duct mid no kmwtt fum-iion. Il is ehietiy *il' inter- 
est in that the iircunujlation of tlui<i in lis Lnlies is often the 
beginoin^ of cystic Innior of tho hniiu] li^'nnKMil (aee Fig. 21}. 



Ki«. -il, 




(M. rarovaiium. t. RemtinK of the upperinnet tubos of tho Wolffian brtdy. 
c. MitiilXu ttet (if tube5 rnrmitiK iMrtiVHrinin. d. Lnwcr atmrihlrd Itibci. 
e. Atri>iihle<] rrtiiuliiB cf WitltTUn duct or Hartiicr's canal. /. The terminal 
bulb or hydutid of the Wolffian diK-t. h. The Fallopian tutkc. i. Hydatid of 
MofKORol. /. Ovary. 



The Mammary Glands, whose futietioti it is to secrete milk 
for the ijustenunce of the ehihl nf^er liirth. pr«|>erly lK'l<in;r to 
the re|tr<Klnclive system. In shii[>e the friund is a Hat, .'ionie- 
tiines very flat, hemisphere, its ha.«f nvstinp u|win the jx'ctornlia 
major muHCJe, between the tliini and fixth rih?. liy cutting a 
larjye oniD<]je transversely ihron^ih its npiator earh half wonhJ 
jrive an upproxininte idea of thr >*hu|H'nf the ;_daiid. jiiid on the 
rnt sJirfarr will l>e seen radiiUlriL^ triil«-rnh('. between wliirh 
the pulp of the fruit is ])iaeed. thnt fairly resemble tlio riuli- 
atiiig trabecmUe nf tibnms tiM^tie, Hllt^'n nr twenty in initiitMT, 
Iwtween which the S'H-alled "l(»I>es" nf the .sccretinjr sijl>- 
Rtanct! of the nianiniiiiy ^laiid are euiitniiied, jind wliie-h are 
continuous with tlie eircnniferoiilial tibnnis cnpsnle of the 
organ. Tlie lobe^ urv made up of lubulet*, and the lobules* of 



THE MAMMARY OLA N VS. 



m^ 



Icniiinal cuIsKlt'-sar fa<'iiii) liru-tl wilh c()Iunnmr ('pitlit'liuin. 
E^eh aciuufi etnptieit it.** eieoretioii (the milk buiii^f toniiii:'*! Hy 
deHi|unnmtiijn, futty »Jt'p*ncnilit.MU and niptnrv of t!uv fpillu^- 
lial celle*) tlinnj^h a liltle durt, which miiu-s wilh others lo 
form a larirer iluct f(»r the l(»hulp, aurl the lohular Hurts unit*' 
to terniiuato in a still lur^rur duct fi>r fOt-h lobt*, ttTiiiwi tlii^ 
ffaiitrtophoroH^ dut^, Tlie jriihictitphorous ducts, tilU^eii or 
twenty iti nunjbor, one for rnoh IoIk*. cHniverpe tnwnni the 
nipple^ becoming witlely ililal4'<l a^ they approach it, but nar- 
rowing again as tbey actually outer it The uiuiu ductD have 



Fio. 22. 





^TTT^^^^^^H 


■ 






^^^1 



Globules of healthy milk ; fi:>urtei'n mnnttw' lauution. 



non-rtriated niuncular filires in their walls the eontractionfl of 
which somelimfs cause ttpurtitig of the milk frtau the uipplt^ 
(Stv Fi^. 2'i, |»ajro f»4.) 

Viewinjr the hrea^st exiernnlly. we m'h the a|>ex of the uiam- 
niurv prujtx'tion snrroundeii l>y a pink disk of skin ralle<l (he 
arntfn, Fnini the e^'Htre of tlie ar<»ohi projwls* the nij>jifr, and 
lienefltb the disk is a rirrtilar band of mii.scnlar Hbref^. wbii-h, 
in ciinlruetinir. asi*iritri the expulsion of milk. 

Asnlreaily stated, uiilk \» formed by lireakin^ <lown fif the 
cell wall uf ihe epithelial eelln lining the aeini of the mum- 




64 



INTERyAL OROASS OF GENERATION, 



mury glmifltn. and liheratioii of the oell ronteute, (x>ui:iii<tiug 
of fatty gnuiuli*3» ami lii|tu<l j>rotoi>liiiiiu. The strrptidn thus 
fi»rnie<i i^ riMideretl more Huid by a watery traiisudutioii direclly 
from the bloodvessels. The free fatty prnniiles coalesce and 
ajjgrp^to toother, and thiis form larger niawes called milk- 
fftobules, which are £till so small a^ to be nii(Tosoo|m', uud 
iXHi^titute a fiitty cmnlsitm with the more fluid ]K>rtioii of the 
milk iu which they tloat («See Fig. 22, |jage 03.) 

Fui. 23. 




Lactiftirous or galactophoroiu ducto. 



Duriojr the first day or two of lactation, however, tlie par- 
tielea of fat are held top[ether iu massej* of eonsiilerably larger 
size, ImviiiK ii granular up|ienriini'e. nml ctilled *'oolofltrum 
wjq)iu*c*leH,'* at* seen ill Fig. 24, page <i5. 

The niaiiimary glands nfcvivt* their bhxKi-»*upply from the 
internal niamtniiry and intfrco^^tal arterie;^. Ttieir nerves are 
derive<l fnjui the inlern'slul and thiiracic briinehfs «»f the 
brnchial plexus. They arc iiImi abumhuitly supplied with 
lymphatic vetuHfls, which <)[ieu into the axillary gland& 




MfCSSTIlUATION AND OVULATION 65 

Fin. 2i. 




lowing OiliMttniui find unlliiiiry milk Klo^'tilci*. flntttluy after labor; 
primlpitru, agfj iiiiiuU-LMi. cAfl« Ha.shai.l.} 



CHAPTER V. 



MENeTRCATION ANP OVULATIOK. 

Menstruation it* a uiontlily heninrrljB^ from the uterine 
cavity. 

It is eatletl "catamenial dMkarffe" **»n«w«*," and " metv- 
*frinif ^o^H'," or in (.'oimmm |MirlnMC"e the *' jnoH//i/y KicJtw^jw,'* 
the ** flowrvAj'^ the "itinmj' the *' nnti'jiftt" the " prrttxfx ; ** or 
the woman in miif! to Ih* " uiifirf!,*' 

We have alri'july (IrriiH'd ovnhilion to l»e the (levelop!uent 
nimI innturtiliiHi of oviilif^ in antl ihfir <IiH'har^r[. tVorii the 
tivnr>'. What rolation has this jinnt-ss to tnenslriirttiini ? 

AU>nl the tiino when nil u\'i\\v \k n\H} and booh to U- dit^- 
ohar^fed, the repro*lurtiv« orjrau!*, I'sjxH'ially the 4>vttrie« uiid 
uternn, recreive an exlni aiitount of Ukmd — they liecoine phyaio- 
6 



Ii() 



MF.SSTRUATION ASD OVULATION. 



logically i'oiijreiitetl in untin^iatitm of in»pre^?nati«in taking 
pim'f (iiir the inerihtnml [«Ti<Ml iiii roully analo^ioiis wilii the 
[H'rio<l of •' heat *' or *• rut " ( "o'sinmiioii " ) iti other animnU) ; 
but in the alweiice of imprp^imlioii the extni hIoo(l-i*ii]iply, 
wliifh was dttrigned t*) |>re[i»re the organs for the recepliou 
nniJ 4ievplopinei»l of an imftrtgnnUd genu, fallfl of its natural 
purpose and \» ilist'hargiid in the form oF menstruation. Meu- 
striaitioii is then fore ile[ien<leiit njwm and more *)r U-j* C4>in- 
ciilent with oviiUitiun — thif^ is tlie '*oruh(onf fhmrtf^* of nien- 
slnintiou, so cnMeiL oUjeciiond have lw?en urge*! against this 
theory, FifAt. It in siiitl the nieii^v have reonrrwi aller re- 
niovrtl <^f Ijotli ovaries. ( Anj»\ver. ThJ.-< is extremely exeep- 
tioniil ; the reriuivat may have l>een iiuM>ni])lote ; there is some- 
limes a tliird ovary ; ' the rtpaye<l wotueu usihI as guards to the 
harems of (Central Asia (h> not meiiHiniaie ; Hnally, the men- 
t*trual discharge, having k-en (X)Htinued for yenrs, may |)er8ifit 
frttm littf/it, even after the origirud cause, viz., ovulation, has 
cea.^d to reeur. ) Secoml, It is allegt^J tliat women do not 
allow coitus an<i l)ecome impregnated «/ the nienstrual [)enoti8, 
hut always between the ]K'ri<«Js, from which it is iuferre<l ovu- 
lation is not coincident with menslruation. (Answer. The 
liiimaii female, like other animals, is really more liiilile lo im- 
jiregiiation when eohuhiting near tJie menstrual |K^rio<!, and the 
same greater liahility [mdiidily obtains tif the [xrio^l did not 
the fli>w [)reveut eohahilation ; moreover, the union of the 
gernw;ell with the s|K*rmHtic fluid <»f the male may lake jdaoe 
at theovulalory peri<Ml from ihe^urvivtil of siKrmatozoa intro- 
duced by coiius a wet-k or iiiort bcfrtre ovulation ; the ovule 
also may remain after l>cinp dischargetl fr*pm the ovnr)* and 
be impregnated ji week or more arter nunstruation. ) Third, 
It is stated that ovuh-i* arc <Iis<'liartred from the ovary without 
any acwjmpauying menstrual Jlow. ( Answer. ThiH may Ik; 
admitted and explained wilfnnit fatjilly nvnllicting with the 
theor}'. It is, however, exceptional, j W hile wme recent 
writers regartl tlie ovuhilory theory of menstruation as a thing 
of the past — of only historic inlerwt— it cnnnol he thus sum- 
marily disiKised of at pn'seiit. True, thoM- who havi- had 
large fXiM'riencf in nMti>viiig the ovaries ami Fallopiito IiiIm'h 
Hnil |K^>rIia)w "bundrt'ils ol" ciu*es" (an o//y/ff/f /J/*/ emivincing 

1 SiiiHn flni»oruuiiit-raiy ovHrlt^ have Um-ii rntintl iwcniy-lhrev tluii-d lit fivr 




WHAT BECOMES OF THE OVULE f 67 

expression) in which menstruation continued afl«r this mutila- 
tion, but all these women were so far ahnonnal as to require 
surgical interference. There are *' hundreds of millions" of 
nomuU women in whom we have every reason to believe the 
funedoQS of ovulation and menstruation are as intimately 
related as they were thought to he before the days of modern 
abdominal surgery. 

On the whole, the ovulatory theory of menstruation is the 
best yet propounded, and must be received, at least for the 
present 

Changes in the Uterine Mucors Membrane at the 
Menstrual Epochs. — Just belbre the flow the membrane 
becomes much thicker, congested, and thrown into shallow 
folds. Then it undergoes disintegration by fatty degeneration, 
and is thrown off with the blood that Hows from the ojiened 
capillary bloodvessels. There exists some dis(Tepancy of 
opinion as to howinuch of the miinnis iiienibrane is thrown off 
every month, but no doubt exists as to the fact of its l)ecoming 
physiologically hy|»ertrophied just before the menses, an<l of its 
undergoing a certain degree of fatty atrophy and degeiieratioii 
■ during and immediately after the period. Shortly after men- 
struation a new mucous membrane is already in <'ourse of 
preparation. 

Some writers affirm that the ovule discharged at a given 
menstrual ()erio<l does not really bel(»rig to that period, but to 
the next subsequent one, thai is to sny : the menstrual jtroeess 
(decidual degeneration) occurring, tx. (jr., at the iiiid<lle of 
February, is the breaking u|i of tlie decidual membranes pre- 
pared for the ovule set free a montli before, at the middle of 
January. This theory, indorsed by high authority, is proln 
ably correct. 

What BEcoMics OF Tin: Ovri.i:? — When not impregnate*! 
it is lost and di.<charg<'<l with the menslnial flow, either before 
or after its disintegration. It is too .^nmll to he seen ; the vitel- 
line niembrane is a mere eeil, , ', ,, of an inch in diameter, and 
its contained germinal visicle measures ~\^^ of an in<*h ; the 
germinal spot ahoiil ..„'„„. The " vesicle " is the nucleus of the 
cell ; the "spot " the nucleolus ; the entire egg simply a mass 
of protoplasm. 



68 



MESSTRVATfOS AND OVULATION. 



The First Mensks and PrBKRTY. — .AfeHAlrualion b^iis 
at ab«>iit foiirt4*en or fifteen years of a»re — the " age of puhrriy^" 
go CJilleii. Tliij* periix! i» pn^'cded an»l attende<.l by wlmt are 
c&\\e<{ the tti/jjtJt <tf puberty. They n)iiHii*t iu the ilt'velopmeot 
of woinutity l^eautie**, ]>hyMoIo;rically ik^ijriied to attraot the 
male; enlargement ami L'mwth of* hair n|>iin the rnons veneris 
nnd labia nmjora ; ^rrowlh of hair in the uxilhe ; enhir^reiueot 
ami incrtuiin*)! nttumlity '>f the hips ami hreiust ; the vulva is 
(Iniwn ihiwnwanl and backvvurd. h* that in the c-rcct posture no 
part of it is visible anteriorly, m it is in children; striking 
changes also occur in the inclinations ami emotional su&cepti- 
hilitius of the wt>niatt. 

Circumstances nioiliJy the a^e at which the first meuHlruntion 
take;^ place : thus, the menses np|>ear earlier in hot ctimat^Ji, 
but the ditTerence between i\w hottfj*i and coldest climates is 
only alMKit three yejin* ; the intlnence of rtic*', which remains 
potent in spite oC climatic cfiani^es ; ort'UfMitioti tttui modt; of 
lifv : luxury, stimidaiilH, indohMUv, hot nxmi-s, pruriency of 
thou};ht. etc., render the worn !iu prccfjcioiin, while op] xjsite con- 
ditions retard the menf**.'ri ; (general rnluistness of constilutiou 
and vig«n»ufl health promote the development of menstruation, 
and it is delayed by feeJilenea* and debility. CJn the other 
hand, a very tall woman with larjre bones and muscles will 
require nn>re time to complete her ^rowlh, and hence the 
reprtwlnclive function!^ will Ik* belated. 

The very rare and uirnpie cawN indisputably authenticated, 
in which children one or two yenr« old hiivc prt^sented the 
exteriuil anatomical evidence;* oi* puburly. and have then mou- 
8truate*l with inoro or less rej^ularity, and have even become 
mothers before they were ten years rild, arc mere medical 
curiosities — (u^t* uniunr — of but little inj|>ortiu discussing the 
physiology of thi.-^ ■JubJMi, 

RvMPTOMrt OF MEXsTRiTATiriv, not always present, are las- 
situde ami deprtwHion of spirit.s he«dache» backar-be, chilliness, 
wei;;hl in hy|M)i::u<trium and |wrinenm. nausea, neural^da^ hys- 
teria* perhat^ slijrhl febrile excitement- They vary in kind 
and de^n:^ in ditl'erent iinlividmds. and are gentrally rclieve<l 
by the flow. The (ii-st few [KTiods are apt to be irrejjular 
ill their recurrence, an*! the tlin-har^re ia t^li^ht iu quantity 
and conqHts«^<I of mucus with but little blood. 



yORMAL SUSPENSION OF MENSTRUATION. 60 

QUANTITV AND QUAUTIES OF TIIK MkXHTKUAI. Dr». 

CHARGE. — The qitantUy of diismharge, when the fimctiuu has 
become regularly "established/' is from one to ei^ht ounces, 
the average being about five ounces. The duration of the 
period is from one to eight days, the average 1)eing iive days, 
henoe average daily quantity during that period, one ounce. 

The menstrual blood does not coagulate, owing to admix- 
ture with vaginal mucus, which contains acetic acid. If the 
flow be very profuse, coagulation will occur, l>ecause the action 
of the vaginal mucus is then insuihcient to prevent it Mucus 
of any kind, in suiiicient quantity, will prevent coagulation. 

The discharge also ditlers at different parts of the period. 
Toward the beginning and end of the e{X}ch it contains more 
mucus and less blood ; at the middle of the period vice verm. 

Source of the Flow. — That the flow comes from the 
uterine cavity is ai)Solutely proved by the following facts: it 
is found there, pod moriein, in tliose who die during menstrua- 
tion ; it is seen to issue from the os externum uteri in cases of 
procidentia of the orgau ; it has In-en seen oozing from the 
uterine mucous membrane in cartes of inversion of the womb ; 
and when there is me(;hanical ol>8truction of the os uteri the 
menses do not appear, but accumulate and distend the uterine 
cavity. 

ViCARiors Menstruation. — This is a flow of blood from 
some other organ recurring at the monthly ])eriods and taking 
the place of menstruation. It may oc^mr from the hemor- 
rhoidal vessels, the lungs, the skin, the nails, the mammary 
glands, ulcerated surfaces, and many other jmrts. 

Periodicity. — The monthly recurrence of menstruation is 
accounted for only in i») far as ovulation exj)Iains it The 
interval sometimes varies from the typical twenty-eight days, 
but it is, then, .strangely, some nuiltiple of a week. 

Normal Sihpknsion of Micnstiiuation. — It is tem])0- 
rarily suif|XMide(l during prfgnancy and lactatioi*, and ceases 
permanently after the so-called *'<'hange «)f life," at alK)ut 
forty-five or fitly years oi' age. Numerous exceptions must 
be noteil to each of those statements. 




70 OVVM: MATVRATIOS, FECUyDATIOK, NUTRITION. 



CHAPTER VI 



MATURATION, FEtrODATION, AND NUTEITION OF THE OVUM, 



MATt?RATrox OF THK OvuLF- — The ovaries (»f a new-born 

rhild iilrcady cmitain the immninre ovnk*.*' that hittr in life, 
and afti-r l»H'oiniiijr rimlure, will hv. diK-hrtrj^^tsi at the m«*u- 
utriml ]M.TiiH]ji or l>c<*ome in>|irc*rniUe(l. The ovule ili«*harged 
trimi the ovary hy a woiimu of*njrhlet*n is thoreiore. in reality, 
alx>ut eijr!iteen year* old at (he time it eseajtes i'mni the uvisac. 
l>urin^ all this time the ovuli'.-i have lufii nctiinl living' lM*ii)pa, 
leiuling a low form of lite M^nethiiij: like (he flnuelm of the 
out>iide world. Like the ania-hn. the ovule th>al8 in a Hiiid- — 
the liijuor (lilliculi ; it jKSK'Aies ainahoid niovenieiit, carries 
on a slow luuritiou, and |>rol>aMy conijtetes with its neighbors 
ill the Hlrii«r^de for exit^teuce. After puU^rty, at hiated j^eriods 
of about a month, one of the.«e undeveloped iinti imtiisiture 
ovules enttrs u[w»n a Boniewlint more active and exalted [xlane 
of life; it heconies mature and ready for fecundation, and is 
then diwhar^ed fnmi the ovarian stroma, as explained in 
<'ha|)ler 1\*, |)uj:e 4.*1. 

The change? that take plaee in it hefore and independent 
of fiM-HTidation are iv* follows: the jrerinimil vesncle, inf^lead of 
remaining' near the centre of (he e^g, Hoats toward and touches 
the vitelline nu-mhrane, and then, chinpilinjr iti*ell" into two 
poles, projeets one of the^e pole?* throu^rh the vitelHuf nieni- 
itrane into tbo i^ri-vitelliue space; the f/tifar rjluindf thus 
extrudnl is coni*tricte<l ol! and eoniplelely f^eparateil fmni the 
perniinal vesicle. Thin process \» once more repeate*!, and a 
second |>olar globule it* extrudeii, constricted oH*. and fe|ia- 
rated. After dischar^nj: thei^e two polar plohulea (which 
were really portiont* of itself), what remniuH of the germinal 
vesicle reee^ies hack ajrain to a more central position in the 
€gg, and thi? remaining |)ortion is now call e< I the *'Jfmn{r pnh 
nuelmt^y The ejrg is now ready lor ternndation. The dis- 
chariee of the polar jtrlohulcH and the prcparuliim <if the tcmale 
pronucleus for fecundation may lake place either ln'fore or 
after the dipt4iarj:e of the ovule from the ovary. It has been 
8uppei*te<l that the discharge of the jHilar globule** is <It«igued 
to make room for the entrance of the male element, or sperm- 



FJCCITNVATIOX OR IMPHEGSATIOS. 



71 



i-ell. au*l nlwi tliiU it prrvents ]mrlliiMio|^(.>iK%tiH, which luay or 
imiy not Xte true. 

Fecundation or iMi'iiKONATtox i.*< ib** union *if the perm- 
cell (ovule) with the R|>erin-<vll <if the male. 

The itj/rnnafir Jhn'/I (bperm. WMiieii, N-rtiiniil ihiifl ) is a \vhiti*<hp 
viseid Huid !*eereleii by the jU'enitsil ;.'luinls of ilie iimle. Klimt- 
iti^ nlH>iit in it are miJIiuns of his'ttjlnizii^il ylfinenli* re»4eniiiliujj[ 
riliutetl epitholiiirii fells, called Apfrnwtnzotx (6|x'rnintoz*ii(ls). 
By waviii"! of its l<»»^ ciliuui the sjiernmtozuiii moves about 
at a rate, it is c^tirnate^l, of one inch iu iteveii and a half min- 
utes — a facility whieh it may retain for eight or ton days after 
l)einp introduced into the female genitail or>:ans, and upon 
which the fceuu<latin«i; |>ower of the sctnen chiefly defends. 
They have Ikh^-ii found alive in executed men three days iil\er 
death. Thev are desitroveil by mid solutions, and are enliverietl 
by alkaline ouch ; thuis the ulkaline niu<'us i}^ the uterus is 
favorable to their activity, while the acid vafjiiial i*e<:Tetiou is 
destructive. When brouj,'ht in contact with the germ-cell the 
spermatozoa pet into the ovule by penetrating the vitelline 
membrane. This union may take j)lace either in the ovary, 
FaHopian tulje, or uterutt. Kwe:it invcHti^rators atfirni that only 
one 8|»ermatox<>iil in <NMicerne<l iu a uomial in»pre;;nntion. 
Several of them may jjcnetnUe the zona |»elluci(la and pet 
into the |ieri-vilelline sptiw?, but only one enters throuj^^h the 
internal vitelline membrane into the vitellas. WhoT» u hjkt- 
matozoid in the iieri-vitelline njiace appruathw the yolk a little 
project inp elevation of the internal vitelline niendtrane is 
thrown out toward it, which the sjiermatozoid nuiy [penetrate ; 
or, iHjfore this penetration, the projwrtinp elevation is with- 
drawn, leaving a slipht hollow or depresnon, into which the 
siiermatoztiid enten* head lirjit ; and the hea<l havinp entered, 
the Irn'omotivc tail and central {tart of the s{H!rniHtozoid are 
left outride in the |)eri-vitelliMe Hpace. The head of the 
8|)enn-eeII, now inside the ovule, is called the " mtitf piui- 
nncfruj*,'* II is iuleri'stinp to olwerve that ax the permiual 
vesicle dlKchnrijtti \{a |>olar plobules into the jKri-vilelline 
8]iuce in cmler to bec<mie a ••female pronucleus" reiidy to 
receive the mule element, no the H|)erinH.'ell h''tvc» f^hhui 
in the same jjeri-vitelline H[»ace the tail and cx^utral jwiiion of 
it« structure, in onler to Ifccome n " wju/'* pnmucUun^^ reiuly 



72 OVUST: MATUBATIOy, FECUNDATfON, 2<VTR!TS0S. 



fur union with the feiiiHli*. The nmlc himI foiiiiilp pniiiuclei 

ini«i«le the vitelliiH approuch wu'h otiier, Irnvel timard the 
centre of the e^'^. reiimin in (intact lor h lime, iiml linally 
fuDc tof^ther : fetrutidutioii '\% then complete. The whole ovum, 
after this uniuu of the ntnle iind t'emule proiiuelei, in ctnllefl the 
" Owt/H-nn** (u**o, an egg; *T::€f*;in, seed). The natural recep- 
tacle for the semen {receptacnlum scminis), in the act of 
coition, 18 the aivity of the utcrn?. whilher it i» con«liicte*l hy 
the five or six snc^'asive cjai-ulutory jct^ on the |wirt of the 
male organ, and the five or Hix Hnctional ii.spiratiun8 on the 
part of the os and cervix titeri that mvur when the orgaj^m is 
iionipk'te ill ImMIi ^*exw hiniulliiueoiisly. It nfterwanl goes on 
through the Fallopian tube to the ovary ; though it is not at 
all improlmhle that itie IuIm^ alHo l)e(x>nie the rei'ipienta of 
eemeu during the sexual orguwm, or during the few hours 
einhracing w'veral «mve#«ive i^exual act.s. Henw tht'oreti<ral 
8|X?i*ulation8 Imij^mI ii|K>n the allege*! fart that it re<piirefl eight 
days for the ovule to \)t\m along the tul»e to the uterus f)fJo)e 
it can become imprcfjnatrd amuut l>e Hu.stained. Tuhal preg- 
Danciee directly negative tltiH »u|j})osition. 

CfIAN<;I» TAKING PLAIK IX THK OviM AI-TKR FwiNDA- 

TION. — At first the fei'undated c^g is- wniply a cell. Its cell 
wall is the vitelline nieniltraue ; its (vmKMith; are the granular 
vitellus (or yolk) and n nucleus, which hist, we have seen, is 
now a somewhat isuiiplcx strnctnrc. being (^imported of the 
male lUid feniule proiinclci, t'tjjellier with that |mrt of the 
germinal vesicle whirh r**innine<l afWr the sepnratitm from it 
of the pjhir globulw*. The next change is ^rtjmruUttlon of 
the vitellus — not of the vitelline 7nrmbratH\ but of the vitellus 
within it. The nucleus Hna divitU% then the (vU. The two 
cells thus torme^l divide in a simihir manner, and four are 
produced. The four divide into eight, the eight into sixteen, 
ami this dichotomous subdivision ntntimien until a great num- 
Ikt of cells arc |>ro«bnx'd. The cells thus fornu'd :irrang© 
themselves in a siKM-ial niamier, now tn he d»T*<^Til»ei|. 

The two cells resulting fnun the first segmentation differ in 
Kite and ajtjiearauet, as well iih in their inheriliMl endowments 
and future destiny ; ami so do the two groups of cells resulting 
fnHM their further subdivision- The larger cells are called 
" epMusdc ceiU " (" e.piblastic spheres " or " ectomeres " ) ; the 



ciia.\(mJ:s l\ or cm aitkh rjcci/yDATJos. 73 

final ler on<« " hj/} of >f astir crlU^' (or '* /iJjf ith/iiMt if jfffhtrtH,'^ or 
••enidinen-j*" ). 'VUv r»'Iuliv«* nrrnii|:t'nuMit of ihc-sie two jLrroujM) 
of wllfc (luting llii-ir earliiT >^»jlnlivipions iri well heen in Ki^. 25. 
A little IttltT llu- hy|M>lilai^t wild collwt as an irregular eeu- 
tral um^ ^liile tlie epihliuit cells ure di8|Mje$eil uroumi them, 
»t iL-* to cover ihein up ami rfurrounil ihcin, except nl one point, 






aU. 





Ftnt Gvv elAfK» )*f 8cen>i-nlation (rabbit's ovum)— fl. ^. ''. '^'. nntl f In a, A, 
•nil r tlip t^pLtiliut relU nn- tarKt>r than th>> hy|HililA«t}c imcs. In rlhe cpiblut 
celU hiivo Iwromt' sniallrr uiul mon* numenms thun Itic hypubUuiiK, And the 
eplUftBttc»[>lii'rvs An; U'KinninK t>> surrnuad nnd cUitv in lUv Uyp^AAtui wU*. 
mp. Tntui iielltitlila. }t. ftt. I'nUr Kl^buk's. rrf. Vint iplbla.Hl ll-II. eM. Vint 



which ij» fjiIUtl ihe Mat^toporc (we A, Fi^. 2f>). This blasto- 
pf>re wHin rln?^*}^. ami then the hyiH»hla.«lio niafisis r»/r'/r/v rl(«*e<| 
in antl ^iirroiiiule«l hy epihlni^tie cells ( Ki^;. 2tJ, Ji). lictweeii 
hY])oltlIl^t iiihI epiiihi.''t n liltle Jluitl ti<*^iiir< to nrruiiiulule, a» 
ihown in M, Fi;r. 2(». Thin (luid iiKTcawH. ninl hepiiin to sepn- 
nite the hyp*»blnKlic cells from the ppiMnMic onej* except Mt the 
rite of the former (hut now ohiiterated) bhistoporc. The 



74 OVLWf: MArrnATfOy, FEWiSDATlOS. yrXRlTJOK 

space between ihc twn s**!."* ol' re.lls is hkiii nipidly I'liljir^eil hy 
thitf Hceutuuhitiiig Huiil. ami (lie wlinle ovum Ihnimiics dititcnileil 
into n vesicle — mivv ralletl the hhiKinilermie vt-niftr. Tlie larger 
part tjf the wall of this (lislemiecl vcsirU* is eoni|M»sed only of 
epihlastic cells, while a smaller p:irt of it is eonipo-aeii of tlie 
Bame epiUla^tic cella, t4>getiier with the wmi^ uf hypohlu^tic 




Two funltcr Aiotfes Adiowinie scenic nun on (rubbli's ovum), tp. Epiblast. 
h^. Hypublost. bp. opeutng In eplbluitt (bliuslnpun;) not yet doBvd. Id B tbiB 

opcoitig All' t'loscd. 

cells Mliirh have been preJ<iH;U a^iiinsL the opiblast by the aocu- 
mulutiiitr Hiiid ""*^in. (Kee V\^, 27, |w^c 75, j 

The blast<«lfnniv . ^ * le eontinues to enlarge: the hy|)0- 
bla^tie mass of eellflr at first leii^sha|K.'(l, is fiattened still more 
and spread <nit over the iiiner aspect of llie epiUlasU but its 
central iK)rtion pi-inaiiis tliieker l!uui its |H'ri])hc'ral marg-in, and 
this thicker part is liieeomuieneement of the '* cmbrifoiiic ar^a,** 
Let it be espe^'ially noted here that at tirst the embryonic area 
only lines a jMirt of the inmr surface of the epibhist (Fig. 27), 
hence the remaining [Mirtion of the IdasUwIcniiic vesicle (ami 
comi»osed otilif of ejiibbist cells) must lie known as the uon- 
embnfonie part of the ejjihlast, \'iewed in a profile eei'tiou, 
the endiryonic area might be corHpart*d to the crescent of a new 
jmKin, while the rest of the lunar glolie would be represented 
by the uon-end)ryonie jwrtion of llu- bhislnderiuic sphere. 

The endiryonii^ area, iKjMiiKise*! of IiyiHddast cells ami mv- 



J 



CHANGES m OVVM AFTER FECUNDATION. lf> 

ered with epiblant, now separateH into two layers — two rows 
or plates of cells — one external to the other, the external one 
having the epiblastic layer outsiile of it Now an event occurs 
that conaplicates this description and involves some rather 
confusing terms, viz., that iK>rtion of the epiblast in contact 
with and covering the outer surface of the embryonic area 
gradually gets thinner and eventually disappears, so that the 
external layer of the hypoblast lUelf becomes the outer sur- 

FiG. 27. 




tp. Zona pclluclda. ep. Epiblast. hy. Ilypoblaat. bv. Cavity of 
blnstoderniic vesicle. 



face of the embryonic area, and is henceforth to be called 
"epibkutV* The former epi))la4't layer that di8ap|>ear8 may 
be remem])ere4l as the ** primitive" epibliist, the non-embryonic 
portion of whicli is continued ovfr the remainder of the blasto- 
dermic vesicle, and, while it helps to form the amnion and 
uml>ilical vesicle, has nothing' to do with the actual formatioij 
of the endiryo itself Thus iar. then, the bwly of the future 
foetus consists of two layers of cells, produced by splitting of 
the original hy]M)blast into an outer and an inner layer — the 
outer one to be called '■'• e]>iblu^i,*' the inner one '* hypohf'it<t." 
A pn)tile section of the ovum at this stage is represented 



76 OV^VM: MATVRATIOS, FECVKDATION, SVTRITION. 

ilia^miiimiitirally in V\^. 2M, in which, however, the primitive' 
cpihlm'l i-elln u-ovcriuK tlic ouler layer of the hypohIm<t) have 
not yvt dii«a|){>eare<i. 

Later on u third layer of cells deveh»p8 lieiwceu the embrj*- 
onic epihlant and the hypoblast : this is the mrnftltlaftf^ or u»t*o- 
derm. Thftie three liiyera of cells — rpiblanfir, mfmbht»ite^ and 
hypobUtMic — *fO()u lorni three nieinbrane*:, fnmi which all parts 
of the future f*etiw are to be develo|»e<l. Exaclly what orjrtma 
are evolved from each of these meuibranee is as yet unsettled, 

Fig. -JS. 




MArotnalion HIo.«^tf.dcrmlc Vofllcle. 
^/. Non-enibryonlc epiblosl I'stcnthng uU Bmuml the ovaro, hot wlilrh will 
diBa[»iH-'nr Intor over thet^mliryttnk' ari'A, wlieii tli(.< outer Uyer or the hyiKiblut 
will hcLiMDL' the embryonic cplblodl, 41. hy. Uypoblast. y^. VcU-mc. 



hut recent iuvestipation would seem to warrant the following 
arraiij^enient : 

The CftihlaM. Cor ectoderm) (external MiL«ti>derniii' rm'm- 
braue) forms (he epidermis and its apfH'udii^^eH (liuir uud 
nails), its plands, including the nianiniiiry glands ; the nervous 
system (bmin, spinal cor4l, ganglia, and nerves), and the organs 
of spe<!ial seiis^;. 

The mffitibhttf ( mesoderm, or mithlle blastodermic membrane) 
/orms the nuisclesi an<l skeleton (b<>m% cartilages, litnimcnts, 
connective lif^jueji): ihe heart, bloiHlvcjisel.s, 1)Iixh1 glands, and 
spleen ; the lymphatics* ; the genito-urinary and reproductive 
organs. 

The hffHibiaM tenloderni, or internal bhtstodermic mein- 
braue) forms the epithelial lining of the digestive canal ami 
of its glands, and the epithelial lining uf the lungs and air- 
passages. 

Ivk now studying the development of the ovum it must first 



CHAyOKS IS OVVM AFTEll FECUNDATION. 77 

l>e um!ereioo»i that nil llic ('hnii^cH to ho related take plaeo 
(hWh* thf ritffilnr mtmhr'inr, whirh, thoiiph extremely thin, 
deli<*iite, and ftotX really play:* tlie piirt of a sort uf e^jrshell, 
inasmueh ik» it e^jiitaiiiH all the uther slrueturw* of the embryo 
with which we have to deal. Moreover, tlie vitelline mem- 
brane doea uot break mitil the end of pregiumey, thouph, aa 
we shall see, it l>ecu»(^s lost by extreme attenuation and by 
amalpam.ilioii with other niembrnuei* liiiinp itn inner snrtaee. 
It' we now supjKww ourselvt^ to bxjk down \]\H)n the outside 
surfaec of the c[>iblnHt (cither looking (firoittfh iW vt!t_'llin6 
tuenibrane or s»ij»[M>hin^' it lo be rernovwl for tbi.H inHiKftiou), 
we ol«erve a <X'iilra! |>art of the embryonic area to l>e more 
transparent than the rest: it is called the " arrn jteUticida.** 
Imme<liately around ti»i» is a more opaque Iwrder, the are<t 
opaca. The firBt visilde trace of the IkmIv of the embryo 
appears in the area peffucida : a line of celln near ita centre 
becomes darker and constitutes tiie '*/>n'm(7iir ttireak,^' which 
was formerly (bought to be tlie beginning of the spinal canal 
or spinal column. This is not so. While the direction of 
the primitive streak arrrees with the long axis of the future 
eMd)ryo, the end)ryo itnelf develo|»* in front of the primitive 
streak, which last is teni]iorary, and so*jn disappears. The 
** streak** is thought to [)e the remnant of some an(.v»tnil form ■ 
which existed l»efore the evolution of vertebrate organisms, ' 

The establishment of a s]Mnal column, spinal cnnal, and 
central nervous system (h)os indeed a|ti>ear to constitute the 
(«rliesl Ix'ginning of the organi/jition of the iMwIy of the 
embryo, but tins occurs imleiK'udent of the '^primitive 
iitreak." In the formatiiui of these structures the rjMuHi and 
infmtbiiij^ simultaneously contribute in the following manner. 
The mesoMast <H:f1ls sejNinite from the hy|)ol)last and mass 
themselves t<igetber to form a distinct rod in line with the 
future bncklxme tif the embryo. This ri»d iw the " luttorhord" - 
From it the 8]>inal <;olumn ia develo|>ed. At the same time I 
the epiblast l>ecoi)iet> ibickened (by multiplication of its cells) 
into two bMigitudinnl ridg«-s t>r folds running parallel with (he 
uotochord (out* on cnrh sidt* of it) and ronlinuiug arouml that 
en<l of tho riotorbitrd when* thu beaid nf the falus ij» to form. 
The epiblasiir ridgfs arc t^dl^d " tiuftuUnnj fuhlA" and the 
trough between them flic ^"mninU'tnj ijrDtnf.^' This gnH)V« 
euda nntcriorlij by the headJuUl^ and, later, it ends jtoHeriorhj 



78 OVl'M: AtATUHATfO.\ FECUNDATION, NUTJUTIOS, 

hv tlio taUfnU. Kinnlly th<<ee rimug tulds on the bides and 
ends of the nieduJlary groove arch over, mwt, uiul joiu, thiw 
iH^nverting the groove into a witml — the '* urtintl <ijttul" or 
medullar}' tube — which ib thus liued with involuted epihla^t, 



Fig. 2d. 



Crofis-Mction nf cmbryu tn the dnntal region, Bhowlng heglnnlnp of medal* 
larjr fuUI* nud gnutve. m, hi. MciIulUry {u\tis,. j/. MfiuUary gro*>ve. ep. Epi- 
b1&ti(. n. Notoclmrtl. Ii. IlypoUlilJit l.l. Vvrl\iheTA\ fAatva oT nn^nhlast. 

and vvbicli rciiinins throughout life as the central cunal of the 
Bpiiinl cord niul iiR the third, fourth, and hiternl ventridea of 
the braiu aud the j>a>Mi<;t^ uuitiug them. 



rk 

mN^ectlontnTncliounilatprtbiin inFls.39. nc. MeOulUry fnldn. */ MvOul- 
Ury groove I'losinff in. 171. KpfhtAKt. A. IVrlithenil plateit of ntcsoblast. ch. 
KoUwIiord. lift. HygxtMost. no. Aorllo Airh. p. rommcnctnK Rlit In mfsohliul 
lU'fHiTiitihK It hilu annininpK'nrlc tiuA s'lilniK-biiopIciirii' InytTs (tlit-sw^' lii*l hi be 
tpoliun uf riirlliLT (III). 



The sevend Rta^res in the fctrnintion of tlie medullary fol<l*s 
groove* un<i canal are shttwu diii^Tamniaiically in Fip*. 2!>, ^-tO, 
31, and .'{2, reiiresentiny erosii-iiwtioiis of the e]id»r)'o. 

ii?oon aller (he forniutiou of ihe ujtMluUurv fohln, with their 



ClfAyUKS IS OVVM AFTER FECVSDATIOS. 



tenninnl heAil- and tail-fdlils. as just describt^d, there l^egin to 
appear ** iaUml foitU" (turiiierly callt'il "abdorniual plates"). 



Fm. 31. 




rroBs-wt'tlnn of embryo In cenfral ivnion, f-howlnif I'loKiire of tuednUary 
groove. .*fr. Neriral mnBl. >W. EpiMuft .1/'^ Pari «f mrsoMadt uhirh will 
untie with epibloAl to furm the Miiimtopleure. MtV. Part uf mcsoblut which 
will bccittiii* thu splKiichiK'pleiin'. fh, Ni>tiM-rhonl. p. ConuiivnciDg pleuro- 
pcritcjiwAl CATiiy. tut Ily|Mibliiiii, tut. Arirtl^' urrhm. 

These will eventually cKwe in the aUluniiiml or Iwdy cavity, 
ju8t as the me<lullay f'olda ch^swl in the t-avily of the neural 

Kl*.. 32. 




Crura-fiortfon of cmhoM in doniftl rejrlon, showing extension of mesoblost be- 
tween epiiltTiiial vpililust un'l Inroluied portion of (rplhlnHt lining neuTitlcAniiL 
Kp. Rpidonnnl opll>]iut. .V. KplhtoMt lining niMtrnl niiinl \'\' t'n<llvltlLil pmt 
of tncsobliiflt. /'. .Mi'fluttlii^tlf IttytT furnilnK l»"«ly wall (w>ni«tnp|purc). />/'/'. 
Mcwibluiitlc Inyer forniinu: inU-}<tlnal walU (Mplnnrhntipltrurc). A* Ni^tooliord. 
/*/*, CnninnMioUnt pleiir»^i-iK'rilonoal envlty. 

canal. The t^ide folds are continuous with the head* ami tnil- 
folde^ but they project in un opposite direction to that taken 



80 OVUM: MATURATION FECUNDATION, yVTRITION. 

by the mwhillnry folds (as shown id Fig. 30), i e., the meiiul- 
lary fol»U hofrin hy projpctinj? Imckwarfl ami niwX in the 
median lint* of the back of the ftetus, while the hiiernl fohls 
begin by projecting fonmrd and meet in the median line of the 
aMomeiL. 

In Fig. 3'i it will )>c seen the three layers Cepiblast, meso- 
bla.«t, antl hyiwbhwt) have extemled over the entire bUiiJt<>- 
dermic veslf^-Ie, but near the |winl hi, on each i^ifle, the lateral 
j'oliU art' bc<riniiing to nppn>arh eaeh other, an<i will eventu- 
ally meet to as to euelosi? and shut off a small |iart of the vesii- 

FlU. 33. 




CroNtspfilion of embryo, fchowing origin of »lde-fiJld». rp. Epiblast. n. Neural 
canal, hy. IlypoMtisl. m. .Mes<tbl«sl. no. Kotochonl. htm. Exti>u>ilf>u of three 
layers (epibUst. inwnWanl. and tiyi^ublast) ovir uuntimbryonic jMirl of bloato- 
dermic vesicle and roveniig yelk-«ac. /i;/. riciiro-pcrilorifAl ravlly. yfr. Vvlk. 



cle from a niueh larger |>art, aa shown in Fig. 34. The 

encloee*! |M»rtioii will become l ho abdominal cavity tiud aliriien- 
tarv ciiiial ; the hytMibla.<t fonnini; the efiilliclial lininL: of that 
canal ; the niei*oblni*t [ilj; inner layer or Ki)liuichuopleure) form- 
ing its mus<-'ular walls; the outer layer "jf the nie^.^ldai'U or 
sonintc^pleuro. forming the muwular wallrt of the alHlomen ; 
while the epibhuM will fonu the epidenniti of the abdominal 
wall. The larger «Hc'ncl(»*e<l jMirtion renmining oiit.side 18 
willed the Kmhiliraf \Tnich' or yelk-Mae. 

A diagraininalic lianjittoiitml i<-r\\ini of the eud>ryo at ihb 
time is sln>\vn in Fig. H*i. 

For w»riie lime tlie cavity of th<' aiimeiitarv canal eommu- 
nicati's with the larger cavity of tin* yelk-sric, bnt the latter 
gradual ly dwindled in nixe am ili^ conletitK are altNirlted into 



CHANGES IN OVUM AFTER FECUNDATION. 



81 



the body of the f<i'lui<. The chanuel of iiilercunimuuication 
becx^mes elougated iuto a blender duct (the " viwlliue duct"). 



Ki.;. M. 




Pla^n^innmLtc cran-«ccUon to show meeling of slde-fbldii. /.'mi Kiuhr^'o. f/e. 
iml PAiml. At Eiic1fUM>il flniAllcr partorblttAtodennic roflicle t'> fonn ntMlom- 

tl cATtly and alimfiiiAry eatuil. }>■ Lm-nclnseil Inixi'r i^n of MaHiutK'rmlo 
Tvsicto— thi' yulk-Mic or umbilical vc-Bick>. Yk. Food-yelk. lathis diagram 
the mc«oblast only is shown . cpiblut aud hy(K<bla»t aiv omitted. 

aud fintilly liie reniaiuB of the yelk-eac coiiHint only '.»f a very 
dimiiiulive vt-siclc i\lJ4ielie<l to tho end of a ^triii^r-like stalk — 
the uow ohliterutetJ vitelline duct. Tliis Ktulk aud vesicle 



Fio. a:% 




Um^tuilinal serUon Miapvmmfttlc) to ahow meeting of sMe-roldtctrwIns 
ftbdomlnol cmvltjr. Km. Bark of embryo. AV, Neural canal. H. Head-fold. 
TaiMfdd. Al Atlmpntary caniil aliiiu»t cU«ed hi. IV Yt-lk-aacor unihlll< 

'CAI ▼calcic. Vk. Yclk-fiHjd. f'h- Kinbryonli- |iliar)'iiE. rr, Flnitiryonlc rectum. 

(The thrcti layers of the hlnntixUTiii are mil shuwn.l 

may be found in the navel strinjj; after birth, by careful di**- 
tMx*lion. 

Returning for a inoment to Fig. SM ('(»ec nlwi Fips. 30, 31. 
and '.V2u it will U* tdiwrvetl that the mrmhtnMxc layer of the 
8idr-foldM Mplil^t in ^«y; ht^rr^, a vWW iH-tweeu them Iwiug the 
e 



82 OVUAf: MATURATION, FECUNDATION, NUTRITION. 



commencement of the pleiiro-|)eri!oneal cavity.* The mtter 

oiip oftlii^sf twft layt*rs of inosnhliif^t unites with the eytibla**t to 
form the hiti'nil ami vt'iUnil whIIh uf the trunk (niuwleH, rilis, 
etc. J. The I'omliimNl o|nhIflf?t an<i ontor layer of nu'sol»lH?!t is 
the ** mvmtitplrun." Tlie inntr layer of the nies»jhlttHt joiuH 
the hy}>ohlHst to form the ** t^jtf/tnchiiopU'urf-,*^ which pives rise 
U* Ihf walls (if thi' iiUnientnry aimil fniuiiculHr eont, ^jlauds 
epilhi'lia! liiiin;r. elt. ). The ^-pinf hetwet-n the two I ay en* of 
niewihhusl is known as the *' mrmbUvfiw cttft ;*' antl hiter on in 
CiUlwi cithm, or " LiHly-cuvitijj" and l)eeom*'« tinally the pleuro- 
|K'rilononl cavity. 

It woul'i lie heyurnl the »cojie of this work to tleserilie the 
development of the variu(w or>;ans of the embryo; the struc- 
tures coue-erued in the uulritiou of t\w fietus wliile in utcro — 
most of tliem l>ein|^ tenijRtrar}' affairs — will, liowever, require 
consideration. 

Alt we have seen, the earlier source of nutriment out of 
which the ImmIv of the fuliis begins to lie h\\\\{ up is file food- 
yelk in the cavity of the yelk-sac or mnhilical ve^icle ; tlie 
channel of corinminir'ation by whtch this nutrient material \» 
carried to ihe folui* is provided by bbHulveK^ds. On the sur- 
face of the umbilical vesicle nmy wmn * l>e peen an artery, vein, 
and intermediate capillanei*^the nm}thnUi-mei^itivrir artery 
and vein — the existence of which pn-supiHiMw that a nidi- 
mentary heart and vascular system have already fivrnied from 
the niestibhist, for these oniphaloniesciileric vessels Jire con- 
tinuijus with those inside the abdomen whidi eventually con- 
slitiJle the [K>rlnl systi-m of veswds. It should here be rioteil 
tlmt the lihiodvcs-*ls of the tmihificai rt'nidr are ijuhe ilistinct 
frcnn those of rlu' ntnhififfil cftnl, which Inst are fonmnl in a 
<l(ticreut manner, troni the nnH of the iiflatiUiiM, as doH'ribed 
further on. The C4)rilenLs of the umldlical vesicle will soon 
l)OfMmie exhatjgteil and the vesicle sbritik alnieist to rmthing. 
Some other source of nutrition for the embryo must therefore 
lie HUjiplied. This is jjrttvidwl for by the developtiieiil, suc^ 
cessively, of the atttnuoi, 'i///oi/«/»V, rhorioiu and jdiicetita, which 
indei'd ha« already beirun Infore the (-(mteuts of the umbilical 
vesicle have disapjM^are*]. 

' til tlic e«rlv ilfvi-Uipim-nl i^fllu' cinbryn the nlriiral nnd ptrltnncal cavities 
«re one. llii- iliK[>linifriti »ii'|<i(rt(iiii).' iIm-iii rMniif^ liiliT. 

* After iHirnlv fmir Imiint" Ifii'iilditiuii nf the hfii'n (.•gjj « niUiniuntar}- bvarl 
Riit] viuH'ulitr trtitikx itm) uln-mly I>l' ilt'iitoiiHtratiKl. 



CHANOJCS IN OVJ'M AFTER VKCVNDATION. 83 

Fin. 3fi. 




SUgcii ill tlifronvcrnlon of lliv niitliillitry i*rii«»vi* into the* neural rftnal. Prtuu 
tAll cihI of I'lDhryn r»r \\\o cat. mg. Hitltillury groove. fi.r. Neural catuil. 
rA. >'nto<'hor"l. r^. KlitMiut. fty. HyptiblML mr. MesoblMt. cr. Cflelom. 
am. Amnion. (Aner Qt'Atjt.) 

liTt it iKtt be overlooked lUtU tin* l»yi»(tl»ln«tic lining of llit^ 
iimKiliffit vei^iclo i** eontiiunnut with llie liyiM»lili]jt|i<* lining of 




84 OVVM: MATVnATlON, FECVNDATTOS, mJTRnWX 

llitj nulinienLar}' iutenline. iintl l)u< hluutlveafeit} uf theee two 
are ulwo cijntiuuous, iiud jierfonii alike the function of ahmrb- 
iiig nutrient vtaierial, jimt iw tlu? I'uliy tievelopetl inteFlineof an 
ndult ahsorlw chyle. 

Now it will be «cou that the snopoofiing device by which the 
embryo b uouril^ll(M[, aller tlie i^hriiikiiif; awny of the iimbilii'al 
vesicle, i.s ajmin an organ or ntniclure wlux^e inner litiing and 
bl(HMivcatiela are contiuuuiis \\ilh tlioK; of the alimeutiiry canal, 
and by which the functiuii of abiJorhing nutriment is" u-rain pro- 
vided for. Thi.« ortrntt licpiiis with the fonnntion of the aflau' 
toix, which iJf to i*urr»nuid ibe fo-tus and to come in conlaot, 
externally, with the nuutjus riieiiibrane of the uterine cavity, 
80 that the Kj>tus lieconu';^ eiitirtly t^urroundcd by and eucloeed 
in a globidar sac — a vawular ba«: — tlie ontside of whicli is in 
contact willi tln^ nt<rine wnl(, and which ii* itwlf a Htrnctnre 
conliimoua with the infant's iiit*'t*l)ne. To nmlerMtand how this 
puzzlinjr nrraupenicnt ran occur we innnt fintt cormider the 
formation of the amniov. 



TiiK Amnion, Aixantoih. anh Citouiov. — The arranjie- 
uieuL and <tuvelopujeut of the:^' HtructurcJs wiil be bei*t bhowu 



Fig. 37. 




n. a l*Tojprling dottUt IbUU "f amnion «>nirwifieil of eplhluiit and Rnmiit<>- 
plcurv of lucsublul. •. Zona iwllucida, or vllt-Uiiie membmnu. ». Eplhliist. 
m. njrfiobla^t Iliilne umtUfcal vesicle and continuous wUb llnfngrof Intosttno. 

V. Vmbllicul vcait^k*. 



by (iiip|MK<inj^ a secticin of the ovum to l>c nia^le in a longitu- 
dinal direction — r. /^., paraHfl with the *«]tinal column, (See 
FijjK :?7. 8S. :^!». and 4(K) 

The iir*t structure ti> bu observed in tbe amnion: it lief'inH 
by the rising up all anmnd Ihc cmbrvo ('l)ebind, in front, and 



TTJK ALLASrOIS AND CIIORIOX. 



85 



on iU sides} of u l)olI(»w rul^r, fold, or (Iiii)li<'ulion of the epU 
bhtfil and uj)|»tT layiT of tlie inewdiln^l (wjimitoiileur*?) ; theHi 
IioIIdw ridgtvi contiiuie ti> ^row U|munl. ur<*|i uvrr ihe dorsal 
anj»o<'t of tlici fo-tus, iind tinuUy nieut and unit**. Wliciv th« 
two nuj^ting folds tourli ejuli oiIkt, the flovihio K-pluni h» 
fonneil hreak.s <lown nud mtdte away ah>iip its cfntre, whih* 
the contiguous oJtjfn of the two niet-tinp \'ti\i\» join each other 
(iiee Fi^. 39); thu>» ii tree Hpace is nuide hctween the ho!h>\v 
cavitice of iht^ two ui»|)ronehing folds, while the union of the 
two inner layers has formed the tuner or true amnion^ and llmt 
of the two outer layers llie t'Mernal ar fahe amttiftn, whieh thus* 
M'fianite from each other. The external |>erijtheral siirl'aee of 
the outer ainniotie layer {Jaiite amnimi) comes in contact with 

Piu. Sti. 




«• a 
X>«V(?lopinent stilt more ii<1vBfm<1. a. a. Folds of amnion about to ttnicli 
and Join each ulher- p (\imm^uccint*nt vf allitntols. 

the vitelline niemhrnne, and these two anmlgamate or weld 
together to form a sin/jle mcmhrane ("suhzonal nicndvrane "), 
while the inlt-ntnf layer of the amnion iirm' amtiion) lieconies 
disteude*! with tiuiil (tiqvor otnttii u fii\i\, ^n^mn^ larger and 
lar^rer during pregnancy, iills the womh, and eonfttilutett one 
of tlie memhranou* ittrata com|M*iug the " hag of waten* " that 
hunttfi during lalK>r. 

TiiK AiJ.ANTow ANi> CHORION*. — The nllantouf begins ha 
a memhranoui* vascular )M>iich npringing from ttn<] contin- 
uous with the lower part of the iIlle^■tinal muojus mcmhrane, 
(Sec Fig. UK) It folIowH inside the s*pace of the hollow 
amniotic pouch, and, like it. wideUK, hpreads laterally, and 




86 OVUM: MATURATIOy, FKCUNDATION, NUTRITION, 



•.'VfiiliiiiUy its two |»n>gre»*ive]y exU'iJiliiig mar>^iii8 nieft and 
join {yich oHier. h) that the fu*Uil Ixxly is now imu'IiwikI w>m- 
|>]etely in a hiyer of nUanfmn^ which, lW)in the uature of it** 
|j]aoe of origin, is, of course, MtiiattHi l^'tweeii the internal 
and exteriml Invars of the aniiiioii. That |iart of llie rtntl or 
neck of this jiiluiitoir mcnihranous sar which remains* outmle 
of tht; alKtoniiiial wall hi-conu-:', and in fart already lA iu a 
rudimentary fortiK thf iimliiliciil <M>rd or navtl Htrinjj; while 
that |K»rtion of ihc^ alhmlois eiirluwd uifhiii llit* iiixlominal 
cavity l)ecomes, later on, the urijiary l)ladder ami uraehus. 

FlU. 89. 




Showlni? Junction nf amnintlc folds ut a «. rinbllical vesicle, jk redJcle of 
allanlolfi. The prttjcctlhg fulilK iiftltc olluiilutfl. itiis.siiiK rounO the crabryo, and* 
fulloWliiK tlic foldii of the iiiuuluti, will sikjii Jtiiii uml unite, cjiiipli'tfly tiur- 
itiunrtlng the uTuiD. 



The canal of the urachus eventually l»econu'H oMiteruUMl, ami 
thus a lii^iunenlous cord remains, coiij-lituiin^^ the middle li^^a- 
ment ol' tlie hludder of adult life. 

The lari;er part of the idlantois — the part outside of the 
al"himinal plates — has il^ cavity olditeruled enrJy in f'u'tal 
lite hy the disnppenrauce of iti* txjnteuts, itrtil hy its two opjwis- 
ii^; folds or walls adherin;^ and uniting ahtii>: their internal 
surfaces to form one layer, which eoiue^ in contiict with tiie 
inner eoncftve surfiu'e of the external anniion antl anialfra- 
mntes with it. Thus the external anuuon lias the vitelline 



TftK ALLASrOhH ASt) VUOIUON. 



87 



inrnihranr on ik<' i^itt.siilo kC it :uh1 tlic alliintois im thv iiwidi'. 
'V\w Ihrw aiiml;,'iuiiuU'(i io;:i*tlKT. n.*» llu-y m»w aiv, nMiijH>:Hi 
n single nieniUmne, wliit-h rotviv** heiniforth the nniiie of 

The chorion arttrManl becK)ni€!A oovere4i exterDnlly witb 
projecting villi, not unlike t[nif*e of the aiiult small inte-stine, 
each of which, lulrr on. rprt-ivej* a cjiitillarv va.*oular Wt\i de- 
rived from what were origiDolly the vesseU of the allautui& 




RbuwtniE folda of altAnloU coroplct«Ijr united, and their two Uyen in onntact 
wltli ciitblHit iiiid vltellliiL' mfmlmiiit'. to fomi i-li<>hitn wlih Itji villi. 1. Vitcl- 
lintf mptrihniiif. ?. Kplliloitt. n. A1Uiitt>lt« ^ riiibilicid Vfitlrlo. .S, Aiimlou (llJi 
Internal laytrr, eoiiululnic llquoriturai). &. iMAy urra*tiu. 7. I\;illt.'leuf«ll«ti> 
toU, to bvct^iii: Ibu uniblUcftl (ford. 



The %yil!i of Ihe chorion, covcrwl with epilheliiini exteranlly, 
and contaiuin^ the Moodvct^fls in llieir iiMilral axtv, jfrow 
longer and hran<*h otit at their di.^tal rxtreniilii*:^, thix priK't^w 
hein^ more coniffli-tr and (ituiplicated in that |Mtit of tlie 
chorion which in In |«irlici|mli' in fnrmiiiL^ the future pjacentji. 
The |»rojwtinjr. daii^din^' villi of llie chorion (oHen termed 
its "sha^r^v coal") ^ive the ovum, when examin^yl [mjhI mor- 
tem, the apiH-arantv of u little hunch of wet, wliilish. trelutin- 
OU8 mo8». After ei^fht wwks the villi over a ^rrcater |iart of 
the chorion disnp|K*ur^ — this |Mirt \» said (o l)econie Mil — while 




88 OVVM- MATVnATiOy, FECUNDATiOSy SVTRITION. 



alH>ut oiii' tliini lit* the surfaoc^ rotAiiiH i(K villi, nnd the laller 
k'ronie (l4*velM|K'<i rtioro ami titorc, Ui furiii, a.M we Hhall »ee 
projjenllv. llu' [»lm'ciila. 

Hiiice the aiiiuioti. aa thus tar fX|f]uiiit<(I, iMfiim (»uly t<» 
envelop the dnrsail iw|rtxi of i\w fo^tiis, wwno furthfi- explana- 
tion is ue^.tawarv iu order to uudfrstaiid liow the whole body 
of the child eventually ri<»ats (a8 it were, tetliere*! by its navel 



FIO. 4L 



Pi«. 4a 





Pig. 41. B. Head of embryo, pp. Tafl p^^rtlon of pl^uro-peiitoDfftl cavllx. 

omr. Tall portion of primitive amniotic cavity (\\w piimiUvc amniotic cavity la 
the hollow s|mco JiiKJdu i\\v rlmiblv fuhlti thul riKe uvtT Itit' buck of the ftvtus). 
a.ij. Tdil rulil (iT aintiiuii. uJi/. llruil fold of nmnion. to. Somalo[tlL>urt>. tp. 
Splanohnoptciiro. fa. Fabtc amnion, ky. ]Iyi>oblafit. 'i/. Allmtiitar)' caiial. 
commiinicatlnK with cavity of ur. the uuibllicul vesicle. 2/'. Z«>iin peDuciUn. 
A. fViTOmcncinp projection of allantolrt. 

Pto. 12. The amniotic foliti have united, Iricloelite oatci. the true nronloltc 
cavity, /a. FuL»! amnion, whom.* cavity, ame, amr.p, in citiitliiuiMiH witli pleuro 
peritoneal cavity. aL Alimentary canal. Ntlll cnmmuntcatiriK with uv, the 
umbilical vcnlcU*. A. Stem of ftlluntotfl dilatinu' into a vcoiclc ni x.»Av. Hypo- 
blaKt. «;>. Bplanchnnpletirc, coinpottcJ <irm> M->blH>( imd liy;x>Miist,nn(l continu- 
oui with nplanchnopIetiK.' orintititinc. Xl*. Zunn [•cllut-iilti. 



strinj») in an nniniotie Imjif that annpietehi surroiindj^ it. This 
explanation is* utt 1'oIIowj* : The t'la.stir anininn ht-nanes more 
and more distended with Huid (the liqinir iiinnii ), mid the Iwo 
end» of the siic, yitddinjr tn this distvntitm, ^Tiiduidlv bwell 
toward ench other, at* iC rollfd iilun;; tlu- niitt'rior siirfVue of 
the fd'tul l>o<ly« initil they nu-et on tlit- ahdnriirn. willi nothiiif; 
hut the undiilical i-ord and thi- reinnintt of ihe undiilira! \v?ii**le 
iH'twH-n them. Tlie wide, roiiniUd v\uh of the amnion that 



THE ALLANTOfS AND CHQRIOK 



89 



ihiw moet over the nlMloinen are cuntinuom^ uith tftf inh'tjumntt 
of thefirh/M, aiiti uftvr (Hmlriliuliii;; a shwilU to tlie umliilicul 
cord, )W just Hliite<l, jf*) uu to join the retlei'twi layer already 
deacrilMHl a.-* roveriajj the dorsal asiK^rt of tln^ tortus. 

To recapitulau* the Hfvenil htrurturw* with which the IVetus 
is surn)unil*-il, iis tluiH l;ir di-siTilKJil, and pHKiet'diug ftvm 
within ouhmnU they are oti fuUuwa : 



PIG. 43, 



Fig. 44. 





Fir;. 13. ta. Ui)., u-.,i.iiii. iij. cftvity. amcJ. bcdniifnif to oxlend with liquor 
Ainiiii. /a. False uuiniun, ilii cHvily, nmr, ctiiittnuoutf wtlli pkuri>-|w-rit<ini>ttl 
cttvJty. m.f. Folds nf true amnion bulgintc nvorulMlnmen ami )M>gfniiinp In form 
nhcAth over iitoiiis of umbilical vesicle ami ulIuntulB. vv. rmbilical V(!i(irlt\ sp. 
Zuuu pvllucida. A. Alluntois. fLM slfiu U IihUdw and continuous vritli cnvily 
nf allmcDtAry cuiial ; at x it is dlUtin; into ii vi'^iclti lin»1 with Itypxtbliut. 

Fin. 14. A. AUaiitoU. Its cavity now obUtemted. II haa spread all aruund. and 
jitlnediiubiuualmembraue icoiui>4«e<| or rftlsi'iintnlontind vltolllnL* in<.'mbrKn(*|i, 
to fonn chirfion. «p. Kemiiniit itf nmbilinil vesicle, nt AHnienlnr>" ctttinl. »j. 
DlUtttl rtHit ofallntituiit within ntxlomi-n, !*> lorni tirlimrb' bladder aud umchun. 
w CommoncinK enfolding to join cavity nf iillmcntiir)* canal, and form nmiilh 
and liiu'ca.! cnvlty : u Hiinilnr notch at tlit.- i-uiiiliil •.'ltd of the vn)br>'o indlcitteM 
tilte nf future anal npenlnic. w.k- FiddH iTtrue amnion fonnint: sheath of uiivel 
Kliiiiic.tind inclofilni; nmtof Bllantois and stem of umbilU-al vehicle. (Tliu other 
loitvn have name rL*A.TencQ as In Fig. 4:t.) 



1. The ttinninti^ i. r.. the hiurr Inyt'r (tf the aniiiiun. contain- 
ing the litpior aniiiii. in which the fcotufi tloatt). 

2. The ailnntuU. 

3. The extermtt ht/rr of thr rniitiinn, 

4. The I'ileiliiie vtfmhrnitr. 

5. Tho threi^ laat-nunied meiiibrauct) weld together to form 
the chorivn. 




90 OVLTAf: MATURATION, FECUNDATfOS^ NVTRJTIOS. 



TIk> I'uniuilitiii of tlu; aaiiiini], jilhinluiH, and clioritin ; the 
p;nnhml shrinkiu;; <if' the uniltilicnl v(*?*icli', to;rether with the 
wiiy in vviiii'li the true iiiiiiimii iiiii] it8 ronteiitK evciittiuMy HLl 
the iiti-riru* cavity, nn<l in whirh tht> uiiiliiliLiil (Miril and tht> 
roii)i&ii):4 mI* thi* iiinl>irH-aI vt\sir'le Ikvouh' n>vt'reil with u shi-nth 
oC aiimiin», riuiy hf ri'iuh'rt'd itinri' t*;Lsily iiitfllijj^ihlt* liy ref'er- 
euL-e to Fi^s. 41, 42, 4;-!, ami 44, [Mi^ca HM and H9 (from Hir4\ 
tSifnt»'tii of < ^tutt'trkit). 

CiiANOBs IN Utekine MiHT»im Mehhrank. Formation 
OF DEC'ir»UA, Era — While the changes tbu» far destTil»etl 
huve iMjeii goiug nil m the ovum, otiiers huve al»o taken place 
in the uterus, es|)et'ially in the uh-ntie miicotuf membrane. 



Ftc.4&. 



Fiu.«k 





FnrniMtlcin of dt*ri(1iiK vers, wtiich la 
represented tiy Itluck colnrini,'. 



PunDAtinij of fii3<lR of tlefilduii reflex* 
throwing uparouod ovum. 



Tlie increased viiH<uhirity, hyjiertri»]>liio thickening, and 
flhullow foMing nf I he uU'rhn' iitiin>us niemlirKiie, whidi. we 
have heen, begin, proparatory to dvulatinn. at each nieuHtrual 
period, progrtas. after the Htininlns iif impregnation, with 
rupiditv. The niendtraiie lK'*'*MiieM exlrt*mely thick, v;ui<*uiar, 
and di^^piy <'onV'dnte<i (except near the uritiees nt* the Fallo- 
pian tuhi> and as internum), ho iw to ohliterate. or nlinost JiiL 
the t*avity of the womli. The hy|>ertrophiwl mucous niendvratie 
thiw formtni on all rtiiles of the iit4;riiK' euvily ifl called the 
tlfcidtia lYrn, 

Wlien the ovnin first entefB the womb it hwlges between 
two (if the fohld of the declduu vera, uud, ini[}urtlng an extra 




CHANOES IN VTERISE MUCOUS MEMBRANE. 91 

Htiriiuliis In tlmae |»ortions of tliw ineiiihnvne inini(^liat**ly »ur- 
rouuHiiitj it, tlit'v ^r**\v \i\\ aill iirtiuiirl the ovum, jiiiil, Ihfiiip rt»- 
Hwt*"*! oyer it, riiert Jtrul join Ui;r<'tlu'r, thus, i\s it wen*, burylnj; 
thf lilth* ^'■errti in it rircnlnr grnvo of nmroiis tiuinliriuit', the 
un'lu'fl rovi'rinj^^ of w liitli is tlu* tlfritluo njif.ra. Timt jtiirt of 
till* ileciilim v»!ra whicli lii'H hrfmrn ilu' ovum niitt iht' uteriuc 
wall I the iuittinn nf our imH;^inarv jirnve) is llu- thrithia nt rtjliiia. 
This l»tHMnii«'S ^rwilly ihickoneil, ninl constitutes the !te<l into 
which the rootlets of the chorial villi |Anietrjttc to form the 
future itltu.'enlu. 

Tluif* the fietiw \» finally euve]ojH'<l hy three nieiuhranes, viz. : 



Fio. 17. 




jQlalUf of foldi of dvcidiia rcflcza amuiiil ovum, ftiut ttilckenliiH uf dccldua 
■iTirfliiA when* the placenta will develop. 



1. The inner layer of the amnion, in future simply r4illei1 
*'Thk Amnion/* for the outer amniotic layer, nn we have 
seen, has lost its identity in Iveconiinjr amalgumRte<i with the 
ftllanloiH and vitelline memliraue to form — 

2. TlIK (*li<)RH>N. 

;>. TiiK l)i:f iniA Kkilkxa.' 

Tht-sie three memhran<« |*erttiat until ilelivery, ixmsiituting 
the several layers of the Img of initerA. In the |int|:reHsive 
development of itrejriuuiry the external Hurfnt-e of llie nnmiou 
eiwncs in etmtaot with the internal Hurface of the chorion ; the 
ext4Tnnl mirfaoe of the chorion in tvmtttK with the internal 
surface of the decitlna reHexa : the external huHikx* of the 

■ It tk uUU Uio dcctUuu ruduJia ImjImiikh uxclusivvly to itiiui. i.-icbrtxMler.) 



92 OVUM: MATURATION, FECUNDATION. NUTRITION. 



decidim reQcxu in cuiitax^l with the tlei'Mua vera, I'overing the 
reniaiiiiuj^ [»irl« of the uterine walU 

lieiVirt? j>n>o<te<liii^ to derfcrilx; th*- lormation of the plarenta 
it may Iw well to uuderslmul that our kuowledfre i»f the earlier 
stagers of eniltryonic evolution ha.s l>ooii derived ulnujst eutirely 
from exiinitnation of the endiryoH of oiher iiiiiiiialH. I)ifin|>- 



F1U.4& 



Fki. i^. 





Showing front tIpw of Rclchen'i 
uiubryo. ■: A. 



Showing sifle view of Rclchert's 
ovum. X 4. 



pointinp: as it may he, it is neverthelefiw (rue that hut very 
few human ova have l>e<'n ttefii during the Hrst two or three 
weekf* after irn])regnation ; during the firt*i week rwue ; during 
the second aud third weekii only a limiteil few ; and, moreover, 



Fig. 50. 




iTbe Mmc lu diagrammatic section. (Hb.) y &. a. Area ecrrolDatira. 



these difler in some eonsiderahle degree from the ova ctf other 
orgauisma — still we must infer they are develo[itM| uj>ori tlie 
Bame general j^lan. Ueiehert'M ovum. i*u|»|M>He<1 to li€ thir- 
teen (L\V8 old, and reprej^eiited four times its natural size 
in FigH. 4M and 4*J, wiw found in the womh of a w<mian who 
committed suieide. It waa tlatlened from side to side, some- 



CHANGES m UTEHINE MUCOVS MEMBRANE. 93 
Pio. &i. 




Hi»'« ovum, spvn frt>m riBtil «ldc. X 20. A. Amnion. A. : AllAnt<»ls con- 
neoUiig with ('ft., ■ |>ttrt of thu chorion. W. IfcArt. V. UUK»il\-(.t««U of K-*., 
yulk HJU*. ur uiiitiUlcul vcaklo. S. Nt'iirHl i^riKivc roriplunl canal. 



FlO. bL 




Bamnn ovum rluring ihin] w*vlc. A. Amnion, At AlUntolc «tiilk. H. 
YitaLti. y BlomlveHcli of )*. *, the yclkHUbc. or timlillit**! VMlclo. (From Hi*, 



94 OVUM: MATURATION, FECUNDATION, NUTRITION. 

ihiu^ like a biconvex leua, the Hurfiu^ facing the decidua 
retleza (showu in Fig. 49, page 92) beiug mure convex than 




Human orum, with contained embryo, about the ond of third week. 
(PrniD KottiXEft, itftcrALLEN THOMnov.) 

thi' other. Friii^ros (if villi [>n)jwUMl only fmm \{» Ixinlerp, tlie 
cuuLni! jj*>rUoar of both surtacf?^ being ImUl uml t:irciihir, iliut 

Pio. bL 




nnmHii t\v\.n% five weeks olJ. (Froui His.) X S. 



(j)W'anl tlie uterus exhihitinij aXm ii t<rnaller rin-ulur central 
space. It ('ontuiiiHl no truce ot* u to'tus. 

A hunmn uvuni, fourteen d:i\> uld, with embryo iiingiiifliHl 



THE PLACENTA. 



95 



twenty diameters, and obtaiued by Hi«, is shown in Fig. 51, 
page !)3. 

Another hnnmii ovum. Ijotwwn fiflwju and figlilt^eu days 
ohl, afl descril>ed Uy Co»te, is showu, largely magnified, in 
Fig. 5'2, page 93. 

At the end of the third week the whole ovum is roverod 
with fhorial villi, and on ciitlitij; it (i|)en the end>ryo may l>e 
seen an represented, oi" uittnral size, in Fi^i:. a.'i, page M4. 

The iiext ilhwtnUioii, Fig. .')4. reprt-senlj* a f'letiw near the 
end of the fifth week, niaLrnitiwl five diameters. 

The in<>re e.\acl apjteaniiices of the faHus at different periwis 
of geatalion are given in Chapter XXXIX., ou the ** Jurispru- 
dence of Midwii'ery. 

The Plackxta. — The plarenta at fiill term is a soft, sp<mgy, 
maes, irregularly snueer-sha])ed, iteven or eight inehes in iliam- 
eter, three-quarters of iin inrh tliirk near llie centre, and fr<3ni 
one-eighth to one-fourlli of an inch al the e<lge ; average weight, 
twenty ouncei*. It varies much in all thes<* |MirtiouIars. 

It iwpins to l»e formed alK)Ut the end of the second month 
of gestation, and attains its enjential eharaoteristics in a few 
weeks more. 

The exact mode of its development-, its minute structure, and 
llie precipe relation of maternal witii fojtal bloodvessel:*, are 
matters regarding which there remains consiilerable uncer- 
tainty. Fh'Ai, It must be niiderst(M>d that the two bhwHls — 
ftrtnl and maternal — never mix. < )n the eontrary, the blood 
sent to the rh.irial villi by foetal arteries returns by fu'tal veins, 
and that sent to the placenta by maternal arteries returns by 
maternal veins. Second, The placenta contains large blood 
spaces — sinuses — filled with maternal blood. Theee blood 
cavities receive red blood from the uterine arteries, which 
returns by uterine veins. The viu*i'ular tufts of cborial villi 
proje*'t intotJK^c bbwid sinuses, snd are constantly bnthed in 
the arterial bhwdJ iherein contained, as is represented diagram- 
matically in Fig. r>5, jtage 9f). 

In the development of ibis urniiigement, the chttrial villi— 
coveretl externally with fo>tal epithelium tderiveil from the 
epiblastj, and containing the fielal blmMlvewielrt, In^tween which 
\i\A and the extermtl epithelium there exist*; a low form of 
ctmne«'tive tissue — grow towacrl tlie uterine wall in the decidua 



96 OVVM: MATDRATlOy, FECUNDATION, NVTHITION. 

fierotiuiu Siiuullaucously the iiiaterual liKeuw? of tbe decidua 
Berotina, carrying inateraal bloodv«wls cMulKfddt?*! in conuec- 
Uvt! lisetue, ^n>w in the t>p[K>Kit4j dirci'tiou, );>t'lweeu thu clumpfl 
ot* villi, ^)iue ui tlit^e (It^'iduuu:^ proce»iH« |H^uetratiDg gtj far 
as to ri'ucli tlu' rhoriunic momhrauc ili*t'lf In-tweon the roots or 
ba««^ ol' the villi ; jii^t il«« some of the chorial tuili). &£ showo 
in V\^. ">;'), have [lenetratt'd ho far in the op]Kwit<* direction as 
U> reach aud allucb their toriiiinat eudn to tUe dec'idua of the 

FiC. 66. 




Vcrtlral M*i-llnQ of « plarpnU. ihowlng vucular ttifU of chorion and blood 
Ukw of plAMnla. a, d. C&orlou. 6. ft. Decidua. t, r. c, r orUlces uf uterine 
alnuMs. 



uterine wall. It is not all of the ohorinl tufts that do this: 
Home of thoni yiniply hang loosely without fixation of their 
diMal cxtroniitifH. 

Now between thtt»e two wtf of strn^tnrej*— f<i"liil and mnler- 
nal — liefwetMi the rliorinl villi growing in one dirwtion and 
the decidual senitina o:rowing in tht^ other — there eventually 
appears a eonHiderahle S|>nce (or 8j«ieei») filled with maternal 

Thetkj are the blood minuses l>ef<ire referred to. How these 



98 OVUM: MATURATION, FECUNDATION, NUTRITION. 

the villi, thus submcrgiug the iRlter in a little lake of MihkI. 
These (»|KMiiiip* are su}i|M>ti'il to lie pnnlmetl by the |ilm;^nritic 
action of ftota) e])itla4iuiii l^jiL)1]<^ llieir way through the walla 
of the luarerual vesnelh. 

In souie way or other the njaleniul bltNMl fiudK its way into 
and out of thei^e iutervillous ^})uee:«; u procesa which is 

Fio. w. 




FtDtal Hiir&ioe uf the plAtcnU. 



perhafie expediteti at iiitervalB — at leaat in so far iw exit of (he 
blood through the uterine veiun is eoneeriied — liy iutennilteiit 
eoulraetiona of the nt^rns, which, it is easy to eonri'ive, must 
also wrrupit^^ or draw together the walls of the plaeetital 
sinuses attac^hed to the uterine wall. The nterine wntraetions 
act 06 a heart for the intervillous eireultUion. 



TBE VMBIUCAL CORD. 



99 



While the t'horinl villi coiituiiiin^ (rr(a! hli>o4lvesscl8 nre 
tbut^ roiiHtAiitly iu (xriituot with tlie innk'riiHl UUhh\ in ihe iuler- 
viUous siiiuijies, it should he rtMiienilxTed that hetwvfcn the ta-lal 
hloofi inside the vt^ycl:* of the villit uud the rruitt'nml blood in 
the Riiiu>ie«, there ttlwayn remains the elements of which the 
villi t.heni.*<elves are coinixwed, viz. : fatal eptheHuiii (derivetl 
from the epihlx«t) n»vering the villuf on its exterior, and i'tetal 
i-ndothelitrm lining; ihe hltHxIvesselH of the villi, and alno 
In-twLi'U these two mmie fa-tal conneelive li>«ue. There is no 
H)r7^n*a^ structure between the fa*t»l and maternal bhxMls; for 
the chorial villi are in dire(^t contact with the maternal bl(»od 
itiielf. which Hows free in the sinust^ uiler having et^cajied frum 
oi)enin;jrH in the niatenm! v<'SS(d:*. 

On insijet^tion after delivery the uterine or external surface 
()f the phu-enta presi-nt;* a dark-rcnl, routrh. and uneven a|)|»e«r- 
ance, with irregular fijj*iurta dividing it into lolnf uj* i*een in 
Fiff. oK, i»age ii7. 

The internal or fa'tal surface in smooth and ^lintening, while 
large hlo<Hlvei#els nuiy Ite .««en and felt Itenenth ittt amniotic 
covering, as shown in Fig. 57, page ilH, 

The plncontn is usually »Huah'fi u|>on either the anterior or 
posterior wall of the uCerus, high up near the entrance of the 
Fallopian tulnt*. This is the rule; cxc<'ptionulIy there is no 
part of tlie uterus to which it may not be attached. 

TiiK I'mbilu Ai, ( v»Ri> (NAVKi>iTBiX(;, Frxis). — At first 
it )A the rt»ot of the allanlois. i»r that {Mtrtlon nf the allnnUiis 
exteiHling from the h<Miy (»f the fietns t<» the chorion. I«aler 
it remains the cimnectiiig link between the ahdonien (navel) 
of the ftt'tUH and the placenta. It contains twci arteries, which 
are cfintinuations of the iVetnl hyjKigiwtric arterii^s. anti one 
vein — the latter without valves, although crcst.vjiUc-8ha|H'd 
folds iMfUiding twiKtIiinb* of the canal of the vein, and llum 
(\»nsiituting im|H'rfi^'t valves, have iK'en de*H'ribeil. The 
umbilical arteries, al tirst straight, l>ecome. later, twisltnl 
around the vein. Tlic vcjwcIs are ind»edde<i in tlie (wwalleil 
gelatin of Wharton, and the cord id covered exteniully by a 
layer of the amnion. 

The cord in usually attached n/'/ir. hut not exactly »'n, the 
middle of the placentiu S»melin»es it is inserted close to the 
placental margin, and is called then *' battlnlore pinccntn" 



100 OVUM: MATURATWS, FECUNDATION, NUTRITtON, 

and "{nscrth mar^nalu." Very rarely it ia inserte*! outttiile 
(ho pliu'eiilal honltT. into the incinliraiifs, iht- unil>iHail v«*- 
seh sutKiiviiliiig and >preudiug out iLelr braucbuti befure 
reachiug the placenta : " iiM&rti4) vclamciiiwfa," 

NUTKITION or FtETUS AT DiFKKKENT PfiRIODS OF 
PKEONASrY. 

1. At first it a1«itr1}8 nniiriHhnu'nl j*iin|>ly ihroujrh the vitcl- 
liut' iiieinbrHiie. 2. The vitellus in iilisdrU-d IVoin iho uinKiiifal 
ve«ifle and farriwi wU* tht- l>ody uf lU* i'a-tun hy tin- hriiiM-hf-s 
t»t* the oiniihnlinru'rtcnti'rir vctist-ls. '.i. The chdriid villi lilisorh 
nutriniput. which is couvfyetl to the ftvliis hy liIo(«lvt>M'Ls 
gjiringinjjj J'naii iht* vimt'ular aDuntois, 4. When a larger 
uutnlxfr of tlie villi have disimi^areil. iIk* renmiuittg one-third 
of the chorial tuita develup into tlie placenta. 

FUNCTIONi* OV THE PLACENTA. — It not Only affvnln HUtri' 
fnrtU to the child, hut is idso ilH rejfjrirofory vr<jitu. The 
umhilical aiieries carry hXwx.- (venous) bliMid to the placenta, 
where ('iirlioiiic aeiil ^nit* is jLriven dfl' to tie niatcrnn! blood, 
and oxygen taken in from ii, ho that thi^ iiiiibilieal vein hrin^t; 
biK'k arterial (red) K|o<k1 to the fains. The placenta is aI»o 
an ortjitn of rjrrrHion for the infant Hence compre^ion and 
obstruction of the cord kill the child. 



F^TTTAL CiKrri.ATiuN. — The unibilicnl vein nfter entering 
the iimliilir'us seiuU two branches to the liver, while its main 
trunk (the dnetuA veiiottUM) eniptit^ clirectly into the aH^endinji: 
vena cava. The bloo<l returned I'mtn the placenta by the 
undiilical vein goes, therefore, part of it to the liver,* whem-e 
it if* returne*! by the he|mtie veins into the nscenilin;; vena 
cava just alwvc the entrants of the ihictus venosus to join the 
current from this latter vessel. The IiI'mmI from the lower 
extremities of the fo'tiis conies up through the vena cava, and 
thus mixes witli llie return hhMMl from the placenta. 

The as<ci!din^' vena cava ]H)urs its bhmrl in1(» the right 
auricle of the heart, where it is directed by the Eustarhkin 

1 Whilo ilif ntntcincnts of «nthi>ritit*i ditTiT ns In wlii-thrr tin- larfri-r p*rt of 

tltl«* M 1 ):>•'* to tli<- Uvpr orinn-etly ttitn the ronn citvti llir>iii|:h the ductus 

Triiii<>ii?i. iliv /(irMt) Hint llii; lar^tT |Mtniou (/cjr« )>afi« ifiri>ii)2h Uto lirurbffuru 
entcrtut; Ibe vouii cavit- 



THE SIGNS OF PREONANCT. 101 

valve through the foramen ovale into the left auricle. From 
the left auricle it goes to the left ventricle ; from the left 
ventricle to the aorta. The great bulk of this aortic stream 
passes through the large arterial branches of the aortic arch 
to the head and upper extremities. From these the blood 
returns by the descending vena cava to the rigjit auricle ; 
from thence through the tricuspid valve it passes into the 
right ventricle ; and then it enters the l>eginniug of the pul- 
monary artery, but the two branches of the pulmonary artery 
going to the lungs cannot receive this column of blood before 
respiration is established, so that there is a special blood-duct 
(the ductus arteriosus) provided for carrying the stream from 
the trunk of the pulmonary artery into the descending aorta, 
from whence part goes to the lower extremities, to come back 
by the ascending cava, while another portion passes along the 
umbilical arteries to the placenta. The umbilical arteries are 
continuatiims of the hyj>ogastric arteries given off from the 
internal iliacs. 

CHANGEfl Taking Place in the Circulation after 
Birth. — There is no longer any current of blood through the 
umbilical vessels. The navel string dries up and falls off. 
The umbilical arteries inside the alwlomen remain permanent 
in a part of their course, constituting the miperior vesical arte- 
ries. The ductus vetiosus and ductus arteriosus no longer 
admit blood, l>ut slirivel uj) into fibrous cxjrds. The foramen 
ovale closes, so that there is no longer any passage from one 
auricle to the other, and when the lungs are exj)anded by 
respiration the pulitionary arteries receive the blood which 
before went through the ductus arteriosus, and convey it to 
the lungs. 



CHAFTEK VII. 



the signs of PRi:<;NANrY. 

The signs of pregnancy retjuire particular and careful 
study, for several reasons : 

(1) Because unskilled persons very oft«n, and the most 



THE SiaXS OF PRKQNASCY. 

fkilful [ihysit-'iiuis .soiut-'tiiiifj*, muke uki^take^ iu stuliii^r that 
pregrmtuiy esisis wlieii it kUwa ihi(, (»r vice irr^a. (2) The 
(juetftioii of pre^^naiicy may involve chanicter, as in uiiniar- 
rii*(l feinaU'in. ('.\) It iiiiiy involve the le^^ii! rijrbts ofcifTiiipring. 
{A) It deleriiiiiu':* imsliral, sur^'iral, and tdttilflriral pro^i'c lures 
oilen oC thf ffravecit itii|K)rt. ({>) It (.otiLvriia the repulaliun 
ul' the physieiuu : bi^ errors Hubjeel hiui to ridicule. 

Ci.AH«iKi('ATlON OF 8inN& — They have heeii divitle^l into 
j/reii^iinptivi\ jtrtibubtr, and jmifitirr, a<*<i»rdinjjr to the dej:r<* 
of reliaiuv to be placed iu them iu» evideuee of pregnancy. 
They have also been eulled ratttmuf^ or tmeh as are evident 
to the senaatiotis of the patiei.l ; ami phifsiati, sueh as bfcoiue 
apparent lo the eduealed pbysieian liy pbyaie-Jil cxaniiimlion. 
i'robably the nuu»t pnutieally usuful lui'thod is to divide tbcm 
into those that nrr certain and lliose tlinl arc imt : hence, yinsZ, 
Positive ititjiui; ifrvontt, Ihtfbtftd xifju.t. 

The duration of preirnancy in the human female is forty 
weeks, tir two hundred and ei<,dily days, or tun inontiii». In 
using the term "month" iu ihla work it will be understood to 
mean a luunr mouth of twenty-eight days. 

How Early DURixn this Period is it usually Posbirlk 
TO Makk A IVfsrnvE I)ia(;noms ok rKi:i;vAN<v in Doi'kt- 

FUL C'AWI-i* WIIKKJ: iMruKTANT IntI:BI>TS ARK InVOLVKD? 

It cannot be far fnm true to assert, (but ihc Tiinjority of •rcucral 
praelitionen* of medicine arc n^t sutiirieutly pkilfid to make a 
I«jsilive diagnosis in such ea^*s before the f»rc;;naney is nearly 
half over. Kvcri the muft r^kilful i^iu hardly obtain abnihitely 
jMisitivc si^n;< during the timl sixl4**M! week**. 

But little rcliainv can Ih- placed u|ion tiie slalcments of the 
woman hcrs<-lf. Without beintr e*>nseiou!»ly untruthful, she 
may ite dweiv«d by her own j^cnsations ; and \n oih^r cases 
Djay wilfully nd^lcud the examiner, even denyin^^ the jfvnn- 
biliiy of pregnancy alnwjsl up to tiie lime of delivery. 

PosiTiVK Sir.NH. — There are only ihree sigua that are also- 
luUly ]Kisitive, viz. : 

1. The fa'tal heart sound. 

2. Quickening, or a<'tive niotiotis of the child. 

3. liallottement, or passive locomotion of the child. 



THE FfETAL HEART SOUND. 



103 



Three others, though not hj vuluable, are usually cloeaed 
with (he [K»si(ivt' i-i^'ii.s viz. : 

4. The utvrino iiiunimr. 

5. Intermittent eoutmctious of the uterus. 
ti. Uegar'fi gigiu 

TiiK Fan-AL Hkart S<^itst». — The pul^tion of the heart 
can eiehK»m lie hcanl ln-turf the twentit-th week (the niiildle of 
|>ro<:nnnev;. A prftetise4l, skilful ear m(/i/ re<'o^M»i/.e It two or 
three weeks wirlier. At* preL^nnncv lulvnnei'H the wiunil gela 
lou<ier ami nH)re ejii*)* of rwojjuition, reseniMin;j that made l>y 
the tiekin<r of n watch heard tlirouirli ii fi-atlier jjillow. A 
good imitutioi) of it may L>e produced by pref^t^ing the jmlm of 
one hand strongly against the ear. while on the Imek or culiitul 
border of it a series of gentle touehe«, in quick 8ueees*ion. are 
made with the rip of the middle Hn^rer of the other hand, pre- 
viously nioistviied with t<uliva ; or a beginner may learn the 
sound by listening to the heart of a new-born child. 

Failure to hear the heart R)undH during thi* later niontlifl 
does not jwtively negative the exislvnee of pregnaney, for the 
ehild may be dead; or the heart wunids may be very feeble; 
or ihiek tumorn. etc., may intervene hetwt*en tin* uterine and 
fllKlominal wall.**, interfering with the truusmitsKiou of the 
Bound : or the auseultator's ear or skill ]iiay be nt fault. 

The j'mjiinirif (»| the fu-lal heart munids bear** no relation 
with that of the mother's heart. They are independent of each 
(»lher. The fu'ial heart Im-hI.** tVoni one hundred auil thirty to 
one hundrtii and lit)y lime.-' a Tiiitiutc. It in generiilly a little 
lepw freipient in large ehiblren than in huiiII uriet*. Very lar^e 
children arc utundly males. Hence, utteinpb* have be<'U made 
to determine the M>x before birth by the hearlBOUnds, but little 
ri'lianee eau Im* phevd in the method. 

It is Iwirdy |Mi>.-ible to mistake the Hound of the mother's 
heart for tlitU of ;i rhihl in utem. i\i> when, rx, tjr., tJie mother's 
heart, from fever or nfher ^'anse, ntlains the same freipiency its 
that of the infant : but thi.-> mistake could be nvoided by 
noting if the mother's pulse l>eat tdmuUttufuuHltj with ibe 
alHlominal sounds. 

When the hounds of the pulsatiouH of the f(eta1 heart are 
diitiiiirlly heard, white the woiidi is f(»nnd tiM> snnill to 4-<mlain 
a ftetUfl of duthcient size to yield a heart sound, and e«|>e(Mally 



104 



TJU': sioys of pregnancy. 



it tlie woiiilt lie hut liltle Iar;rcr llini) an uniniprcniiiated one, 
it iuilicatci- rxtni'utninr i'uiation. 

Method of Kj^intliiiiliim. — Owiii;; lo ifcn* llrxtnl |Kj^iiire at' 
the iiliild, ihe ^^trn Is truiifiniiUed thri>ii,L;h its bark, wliich i:» iti 
closer coiitai-l svilli the uterine wall tlinn are the nihcr jiart^i 
of tht^ iufanl'.-i thorax. Th*' Imrk of tlie rhild uj^imlly lies 
against th** lowtT part nl" (lie iitt-riiie wall on the Icli >*ith*. 
We listen ii»r tlie Mtjii?ii|. iheretoiv, on the nlxloiiitii of the 
mother ahuul the niidille ut' a line drawn I'nmi ihe undiiliiUH 
to the tvntrt' of I'oiJiian's liiraim-iit on the \vi\ side^ or the 
re^^ion thereulK>nls. Kail in*; lo hear the hound there, the 
Baine rej(ii>n on the rijrhl i^ide may he examined, and, if a^aiu 
failin<r, the wlmU* ^surface of the ahdonien niiiy l>e exiih)red. 
The sound may l)e rendt-red more distinct hy preiisini; the (»alni 
of the hand on that part of tfie ul^-rns n|i|M>site the child's 
back, (^ as to (brru the donnal a^^>eet of the infuut against 
the i*ide oi the uteruis to whieh the eiir or stetho8oo{)e i» 
applieti. 

In breech prciientatioji tlie sound is heiird alK>ve the umhili- 
cuii, and in trauisverse castis low down near the ^yiuphyt^iK 
pubis. 

Before the lai^t three months of pregnancy we may hear the 
B0un<l hrttiT over the mciliiiu line in iM)nie cjiMti. 

In au.soultdtion (»f the ulHtomeu a HtetlioKX)|>G 18 ukmI (ttie 
double one pn^ferred). or the wir alone, one thin b*yer of 
clothiuir iH>veriiiii: the surtheo in the latter meth(Ml for the sake 
of delieju'V. Kor various rea.-ionH tin* .•^tettiowitpe U lielter. 
The patient must lie n|»on lier hark, Imu' linilu; extetxh^I or 
niodfrntely flexed, and iheroojn he kept fpliet. FwhU- Mitindi* 
ur*' sometimes divcrh'd hy our hn;rers on the i?lelhos('o|K». My 
Weltinir the iimnth of thr inxtrunu-nt, ho that it will stick to the 
Hkin, it may be held in |M)Nition hy the head of the exauiiuer 
while the linger.-* arc nMuovcd. 



QuroKEMXf!. — Thin tenn oriffinufnl from the erroneous 
eup|)o.silion that the I'liihl lnN*ame '*/|i<iV('," or alive, onlv atler 
it be;:an to move. It i^ipiiply tncfiu" active mn}4('nlar motions 
of tlu' rliild's liinlis or body. The |K*rii>d at whirh fu'tal move- 
meuli! may be first riM'ty^umH] varii^ very much ; hut to make 
a practical stnlomcnt. ami one eiwy of rei'ollclion, we may ?*ay 
about the middle of prrgnaiiey. Then, and atlcr then, an 



QUICK EM^V. 105 

obstetrician of ordinary skill may feel the motions of the 
child, but the mother may be coguizant of certain sensations 
in the abdomen (described as *• fluttering," ** pulsating," 
"creeping," etc.), which she calls '* feeling life," as early as 
the sixteenth or eighteenth week. Occasionally in examining 
the abdomen the physician, at this early period, or even 
before, may feel, or hear with the stethoscojH*, certain motions, 
which he supposes are foital movements, but these are scarcely 
reliable. 

Ijite in pregnancy the motions, when violent, produce dis- 
tortions and projections . of the abdominal wall that may be 
seen as well as felt 

The motions are of two kinds, viz. : a slow, diffnsed, heav- 
ing motion producetl by movementi* of the child's Ixxly ; and 
more forcible quick motions produced by movements of its 
liml)8. 

Failure to recognize thet^e movements does not negative the 
existence of pregnancy ; the child may be dead, or it may 
retain life and vigor, and yet fail to move, even during the 
physician^s exaniinntion. 

Contractile muscular motions in the abdominal, uterine, or 
intestir.al walls, the movement of gas in the intestinal canal, 
and the pulsations of aneurisms and large arteries, may, it is 
just possible, be mistaken ibr fwtal movements by the inex- 
perience<l. 

Method of Exam illation. — Tjite in pregnancy fa?tal motions 
may often l>e discovered while the woman is standing or sit- 
ting, but it is best to place her on her back, with the thighs 
flexe<l, so as to relax the abdominal wall. All clothing, esy^e- 
cially corsets and waistbands, should be removed from the entire 
al>domen. The bladder and rectum must be empty. Place the 
woman near the side of tlie bed, antl let the examiner stand 
close to hfr siile, but facing her feet ; his hands to lie placiMJ, 
palms together, as .mIiowu in Fig. 5H, page 10H. their ulnar 
l>orders l>eing gradually separated and presse<l <lown on each 
side of the uterus until (hat organ is hehl l)etween them. One 
hand should now remain still while the other ntanipulates the 
womb, feeling for any iiu'<|ualities or projections produced by 
the foetus. Pressure thus applied, first on one sifle, then on the 
other, will usually cause tU'tal motions, during which fmth 
bauds should be held .still, thus enabling the examiner to dia- 



nm 



THE sro\s OF PREONAycr 



tinjriiwh IxftwciMi artivi' iiiovi'ihi'uIh of the thihl itself and 
[)U!«ive luovfiiivnls |)nMliif'eil liy Wis owu umitipututiou. 



KlG. 58. 




Ham.ottkmknt — rAKsrvi: LtMuMnrdiN (ik tiik iMtrriTH— 
is a itudilcii lix'ntiitttion of tlie cliiM in llu* uicriiif cavity, pro- 
dareil an<I foil l»y llu^ pliVHirinri. 

Mfihud uj Kntmination. — The woiimn i** placeil in a j>09itiuu 
which will miikf the child settle, by jjruvitntion, toward that 
|Mirl of the uleni!^ where the exaiiiinih;: finjrer i.s I*) he upplie^l 
p«*r tytfjiuft}H. The Ik'.-^! plan is to let her sit (»n the e<lire of it 
low IkmI anil tlieii lean Itaeli a<raiiit^t pillows so ils In he midway 
l>elweeii Hilling arul lyin^'. The finder w imw inlrndiued uiid 
|ilueed in fntril of the ^vrvix. e|rn*e to its junetion with the 
Ikj^Iv of Ihe wonih. (Se** V'v^. 5I», pajre \^)7.) 

The other hand steadies the funduH uteri. A sudden U|>- 
wanl. jerkin^', hut not violent, motion is now exe<Mited liy the 
examining finger, which will cause the f<uetU!« to hound slowly 



BALLOTTEMENT. 



107 



upward to the fundus, and as it comes back again the finger 
will feel it knock against the net^k (so to 8i>eak) of the uterine 
bottle in which it tloata. Tlie manipulations may be repeated 
several times to insure certainty. The |>o8itiou may be 
changed to a lying or standing one, and the finger put l>ehind 
the cervix uteri, if the first examination be not satisfactory. 

The stan<ling |K)sition — the woman placing one foot on the 
lower round of a chair and the examiner kneeling in front of 
her — though indelit^te, sliould always l>e tried when we fail 
to recognize ballottenient in other (>osture«. 

If the alxlominal walls be thin, extentnl MloHement may 
be performetl. The woman lies on her side, the abdomen 

FiQ. 59. 




ExaminBtion by balloltement: ^. Siicrum. B. Rectum. C. Utcnis and ovum. 
/). Klad<k>r. K. Exaiiiiiiiiig tliit^i-r. 



slightly over the edge of the be<l, and with a hand on each 
si»le of the womb the o|)erator endeavors to move the foetus up 
and down fur the purjjosii already indicatetl, or he may apply 
his han<ls to the womb in the manner jnst previously des<!ril)e<l 
for <lis(!overing f<i'tal movements — the woman lying \x\\o\\ her 
back, when, by gentle tapping with the fMiger-ti|»s, the l>ound 
ami relx)und of tlie floating fletus may \w |)erceived. 

Ballottoment may l>e recognized earlier than any <tthcr of 
the |)ositive signs, viz,, from alwiut the fourteenth or Hfleenth 
we(>k. and until within six or eight weeks of full term. 

Towanl the end of j)regnancy the chiM so nearly fills the 
uterine cavity that it cannot be moved about. In multiple 
pregnancies, or where there is deficieni;y of the liquor anmii, 



108 



TUE Slays OF vreosancy 



the HijLrn is uuavinlalilf for tin* Hittiif reiLHiHi. Tliv rliilil may 
also be iiniiioviiIiK' wlii'ii it is lyin;: crnf^swisc in tin* wdiiih. 
Aguiti, thv i)|K'rjilnr muy lark hkill aixl iicutv tartiie wut-i- 
hilily. Durin;; llu- Hrsl iiurl nl* |nv^tuiiu*y llu* rliild i?* luu 
li;:liL ill ^VL'i^lit to Ih' tV-U uitli iltc iiii^r through the iiteriue 

XMllL 

A cjilculiis in tlu* hlaihler, n ])e(li('iiljit('(l siiliiic.ritoncul 
fil>n>i«l tumor of iIk* uUtu:*. a |»rolu]«H'<l ai»<l slitrhily niluriri'il 
ovary, ainl n nmltiloitilar ovarian <;y.sl may )*\\\' n*.sult.** n*- 
r^miliiitij; iKillidU'iiii'iif, liiit lliry ar** r*niiMl hi Ik* oniaitU of 
the uUtus — nut in il — lu* may Ik.' ilistovtTcil l»y the liinmuual 
cxuminatiuu. 



Tin: rxfiHlNK Mi'ltMi'lt. — Tlii.-* Iiil-* U'en ^'jilU'd phirrufal 
munnitr — |tla*^eiital .-uullk-, or Ofuit jiluniitnlrt: — hccmi.sf it 
wait lhou;;lit to he pru(]iitx.'jl liy IiUhhI nishitii; tliroiiL'h the 
'• Iiluivnital HiniiHw*;" tftertuf Htntfff or niiinniir, ihi tin' f^upiMi- 
Hition of its lieia;j; rniiS4'<l in the same way in the art^'fiis of 
the ulernrf ; tibthiuihuif .ttmjfir, Itvnui^i.- it was K'Hevwl to m'vur 
frail [>re8Hure of the ^ruvlU woaih u|m>ii die lar;.'e vessels of 
the ah'lotitcn. It has al^* Ixvn referreil \n liltKw!-oluiiii;es, 
like ihoM' (MTtirriiiL^ in profound ana'niia : and it \^ Kiiid a 
Boniewhat ■^iniihir s<)niiil has Imhmi pr'wliUH'd hy pre?«<ure of the 
sUnhtwroiH' ii|H>n tlie e|»i^';Lsirif artery in tlie ah(hmiinal wall. 

These tlieoriei* are still nii?4etlle<l. Tlie one most ^'Uemlly 
reeeive<l in that which refers the pound to the itfn'itir i»l(M«l- 
elmnnelH, The uiiirnMir luu* Ikhmi hennl s^evernl <lay> nMer 
eoniith'te delivery "f the phu'tMita. ami there i?* no sijl>s!:inti:d 
prtHif of iltf pnidu4'tinii in the veMwl.n of the alMJnnien. 

The rnii>t slrikin^^ (RM-ulinrilies of the uterine miirinurare 
nn fiillowH : 

I. It ill a matertial .sound ^'ytlehronouK \sith ihe niother'i> 
pulffe; 2. It is reinarkahly fapridons or ro(|iiriiish in eliar- 
aeler, ehan;ziii^' oHen in tone. ])iteh. iateiiHiy. duration, and 
l(K-ution. even while we listen, or !l may lie ahnient and aLndn 
return; X It iKMNtinen slronirer at the lu-L'innint: of a lal^tr- 
jMlill, ceases ahoiret her at the aetiie of the pain, returns loud 
rt^'uiii as (he jmin PR'S off and, aller that, n'sunifs the eliar- 
ncter it had liefore I lie pain he^xan. 

It is most usually re<'ojrinzed ntiir tlie lower part of the 
alxlotnen, and neeessurily 8o wJieti lin<t uudihle, lieeiuine thtii 



INTERMITTENT UTERINE CONTRACTIONS, 109 

womb does not yet extend high up in the abdominal eavity. 
Toward the end of the |>regnancy it may be heard, of course^ 
higher up; The Htethoscojje should be placed on the sides of 
the uterus, over the uterine arteries. It cannot generally be 
recognized before the sixteenth weeky except by ears exception- 
ally acute and skilled. It remains afterward till full term, 
unless tem|)orarily absent, as before explained. It is not an 
abnolulebj |H)sitive sign of pregnancy, l)eo-ause a sound resem- 
bling it may Ikj heard in large fibroid tumors of the uterus, 
ovarian tumors, ami other con<litions. In fact, this sound 
never ought to have been clas^d with the positive signs. As 
years go by it is ac<,*ordetl less aiul less value. 

Intermittent Uterine Contractions. — From about the 
twelfth week of pregnancy Cwheu the womb has grown suffi- 
ciently large to be felt by the hand through the abdominal 
wall) until its termination, the uterus is constantly contract- 
ing at intervals of a few minutes. Though a valuable sign, 
from the early i>eriod at which this may be recognized, it is 
not an abmlatehj positive one, because the uterus may contract 
in a similar manner in its cflbrts to expel blood-clots, [jolypi, 
retiiinetl menses, fibroid tumors, and other products not con- 
ne<^te<l with pregnancy. It is of great diagnostic value, how- 
ever, as a <'<>rrolM)rative sign when considered in relation with 
the history of the caH\ 

The contrat^tions of a distended blailder, when its walls are 
\n\\i'\\ thickened by hyiK'rtrophy, might i>ossibly be mistaken 
for a contracting uterus. Km|)lying the bladder by a catheter 
would readily settle this difficulty. 

Method of Kjtfimiuatioii. — Ix't one hand grasp the fundus 
uteri and rcnmin so doing for from /re to fifteen or even twenty 
minufef. It will feel the wond) harden (by contraction) in a 
very characteristic manner. The contractions last from two 
to five minutes. Should the external examination alone fail 
to re<'ognizc the enlarged uterus, the bimanual method may be 
employe*!, one or two fingers of the other hand l>eing passed 
into the vagina to elevate the uterus toward the hand already 
on the abdomen. It is of the greatest importance that the 
alMlominal wall be relaxe*! by flexitm of the lower liml)S, the 
woman lying U|Min her luu'k. and all clothing and waistbands 
removed. 



no 



TJUi: SIGNS OF PREGNANC}: 



HEfiAR'B 8inN. — This h n fhanu:() in tho ahape nnrl ronMMt- 
enctf of thiit part of tlit* Uody of the uterus judt above the 



Fig. 60. 




a. Petr-«hnpe<I vlrirln ulpni*. h. Jug ^Il»fK.•rt iiteni!*. Tho thlnuc^l 
ftcl^iiiLiii 1a tli>riiuMl liy llu> ilollod lines. (IHogmmiimtlcj 



Fie. 61. 



Kio. et 




8hape of nonpn^irnaiit iili>nui. 
(Fnim llinsT. nft^-r HroiN.) 




Shape of titenu' in curly prag^ 



oervix. Tho **]Kyip-.«hapo" of the iinirn|ircirriat<Hl uterus is 
(rhanjrwl io that of an *'olt!-tjiHhion«l. fat-U'llit'tl jnjr;" (hat 
is to nay, the l(»\vt'r Ht'irmcnt of (he hftJv '>|' the uterus, instead 



HEGARIS SIGN. Ill 

of widening grofhially alx)ve its junction with the cervix, 
widenB siiddenbj like an inverted rourtd-^honldered demijohn, 
the neck of which may he compared to the neck of the uterus. 
(See Fig. 60, page 110.) Together with change of shapcj the 
segment of the uterine Inwly inunediately aiiove the cervix (the 
round sliouhler of our fat jug, to continue the simile) becomes 
soft, thin, yieldimjy and elaatlc in consi^stency, while ab(/ve this 

Flu. 63. 




Dcninnstration of Ili-^arV Mpn by tiiinnnual oxamination, the fiinilus twing 
iiirliiu'<l iMirkwiinl. (Sonntaii.) 

yielding ]M»rt tliere remains a harder reflisting |)ortion of the 
uterine ixxiy. 

The change of Hliaix*, as re<^(»gnized by the examining finger, 
is well shown in Figures (11 and 62, page 110. 

Methwl of Kxamhuitiim. — If the vagina l)e spacious and the 
abdominal walU lax and thin^ Hegar's sign may Ik* demon- 
stnite<l by pa.Msing the finger of one han<l into the vagina high 
up l>ehind the cervix uteri, wliile the finger-ti|)H of the other 
hand make pressure externally alK>ve and iK^hiiid the pulH*s, 



U2 



THE SrONS OF PBKOKASCY. 



ftfi hIiowu ill Fi^;. (i.'i. |iuj.M' 1 1 1. Ill msfs where tlio AnuUis 
iiU'ri iticliiies (orw:ir*l, ihc iiilni-va^nnal linger «h«>i]l(l po fii^h 
U|» ill j'rovi (if tin* vervix, while I lie lingers of the (jther liaiid 
uuike prei«iire externally bch'nnl the tuiuliis, as shown in Fig. 
i)4. 

In ciifles (ohivfly iiulii|iflrii\i where the vujona in mU duffi- 
eieiitly s[Mwi(»iis iiihJ the altildniinui wiilU imt .'JufJieiently Inx 
uiul thid U> lilluvv ui' Lhi.>^ <lein<iiifilruru>]i by tlie iiietluHi uliove 

Fig. fri. 




DenioDBtnition »*t lIpKHr'svlpii hy lilmnnun] exunintiticii, the rinitlufi tM'hif; 
lncUDe<l foruapl. (Kohhtag.) 



(iewnlMMl, !i't tlu' iiKU'X-tinper of <nie liaiwl Ih' j^'^w*! into the 
rrHuiit liiifit up, ahuvr (In- uUnclnntnil of ihe tttrn^-itfirruf ilijtt' 
mrtit^, the thumb of the same han<l p<iiiij: into the vagina m 
front iii' the <!ervix iileri, wliilj ilie tinger>i itf the other hand 
make preHHure externally liehiial the ptihes, uh ^hown in Fi^. 
fi-'). page \\'^. 

j\n<tther nielhtHJ is In prtHM Ihr trfiofr ut*rii» dtnni with tlw 
exti^rnal hand, while the tinker i> in the reotuui ntitl the thumb 



HEOARS SfON. 



113 



in the vagina, bs just stated. The tissues just above the in- 
terual oa uteri may now l)e cimipresse*! between the thumb 
and tiuger, and their tinniiess and elasticity demonstrated. 
Sometimes the intervening tissues feel as '* thin cm a visUhig- 
cardy' or the tW^liiig may convey tlie impression of an apparent 
separation or loss of continuity l>etwceu tlie cervix and body 
of the uterus. 

Verv rarely it may be ntH-essary to amwthetiwi the patient 
and draw down the^ uterus with a tenaculum or vulseilum 



Km. tK>. 




Demnnstmtlnn (if Ilogar's sit^n by rocto-VRRlnal examination. (Sonntao.) 



forcei* h(X)ked into the vaginal portion of the cervix, in order 
to bring the thin |)<)rtion of the .uterine wall witliin rea<;h of 
the examining fingers. 

Hegar'fl sign bus lM»en re<v»giiized as early as the sixth or 
eifflUh wet^k, and is of great value at this early <late. In di»- 
e«8?d (Nmditions of the uterine wall it may l»e al>8ent or 
unrei'ogniziible, even though pregnancy exist. S4)me skille<l 
observers luwert tiiat they have ventured a |M)sitive opinion 
from this sign «s early as the fifth week, and which subse- 
quently proved to be (^)rrect. The sign obtains more and 



114 



THK SrONS OF PREGKASCT. 



mMR' VJilnt' ill iirojHirtiim ti» the (jrettttr dftjrrf of thiniu's* iiiiil 
OnrnprKssiliiliiy <>t" llir tisniK'-s n«»*friuNL When tlu-y nin Iks 
Hu L'otii|irt*h(ii^*l \w in \w\<\ IIk* itni)rt'sj*inii *%{' uii nfffmt'fiit m'imi- 
rntioii lK4\v<Mn Ixxly :iml tvrvix tin* vtiliie uC tin- siirn is iit ite 
hi'Ht. Ill H tew iiiHt;Liir(*8 tins iippnri'iit t^i'|f:iralion liiu^ It'd ti> 
th<^ errniiertiis iliiipuisiw of fXtra-iih-niK' prcpiunry. »T*iH'ciiilly 
whcrr tile cervix wii.^ hyfMTtn'pliinl, ihn enlur^iNl cfTvix 
Imviiijj heeu iiiisUikeii for ihc* f»n|y of thr iittTii**, while tlio 
eularfted IxMJy of the pre^rniiiit woiiih wjw tJikeii for uii rxlrii- 
iiterine ryaU A pre-existiii;: hitiTiil flt^xion of the ulcriii* would 
iiirrease iht' liiihililv to such m iniMnke, l^uulioii armnlitijfly. 
Nearly iillieil to lUf^iir's niLni aiul it{\vu ussiH-inli'il wilh it 
is the (Irtiilioij ul' fiuctmttion in llu? tltin uterine t^e^'iuent, 
ert|»e('iiilly of ihc ;iiiterit>r wall. If is lust rceoy;ui/i(l liy juihh- 
iii^^ iiio Hii;;<Ts iiiUi the vn^'ina, arul iiiaiiipuliiliii;:, iirM with 
one, (lien the i^ther. while llu- wnuih is sti'adiei] hy tlie remain- 
ing hami uul.side of the alHionieu. It niav he tell na early &» 
Beven or ei^lit weekn, hut re<|uires an eilucntetl Hujirer. The 
bladder Hhouhl have Imvo previously t-nifilied hy a mtheler. 
It was lirst |KHntetl out by Dr. Adolph K:L*«*h, i^nnetinies the 
fWttt w^enieiit of the uterine /W// rt<*enis to overliip the rrn^fx at 
the anterior fornix of the vui^ina, Ihuri ])resimting a aort of 
ridge or fold eu^ly felt by tl>e exaniiuiug finger. 

Adpitionai- Pityskai. Skjn'h. — In adilition to the fore- 
goinjr six positive signs, iiUHeullation may reveal one or two 
others of less value. Tlawe are ; 1. The fuvir or nmbiliral 
ittmjir — an intermittent, hinpiiug wjuihI, synehrotious with the 
fu'tal lieart. snp|M>sed to eonie from the imihilica! urterieH 
wlien the funis is (viiled around the ehild'a Iwidy nr nwk. 
li. The ''Jtrhtl K/(wi-"— this conveys to the ear a eonihiiuMl 
sensation of shoek and stmiid, and is probahly prodneeil by 
the pretvure of the stelhos<*i»pe moving the fietiis |mssively. 
It is hnlloitrmrnt reeiigiiix»»d hy the ear, instead of the fin(ff*r, 
S. Svunds protliKvd hy nrfiir motions of tiie child. It is 
'' ([ttirh'nituj'^ reeogniwd by the rnr, instead of by the hand 
This hwt is of son»e value, sinee it may 1h» oeeit^ionally recog- 
nized earlier than the other aiis4*ultatr}ry signs — viz.. by the 
end of the Iwelftb week. Neither of th<*se three ad<litional 
signs, however, is comparable, in ])ractical value, with the six 
previously mentioned. 



DOUBTFUL SrOiXS OF PHEO NANCY. 



115 



DoirBTFUL SiGJfB OP pRE<;NA>rY. — Tli«w are. difficult to 
detini' nunii'rically, luit for wmvciiU'iuv ai' nt'ollt-ition we uuiv 
enumerate yiir that are e:i*ty of rt^'(»<jnitioii aiid/iir others that 
are mtmewhat lews jjo. luieli ot' these ten i<ij;nrt, linwever, iu- 
ehides a variety of piu'ivonieiia. They are Jis follows: 



h'irM Fire. 

J. Sup|tre?tt*!oii of the riienHen. 

2. (*hai)^'e^ in the hreaht.s aiitl ntpijles. 

'^. Moniiiii: Mrkne»<s. 

4. MorhiiJ lou^rinp* ami tl^'SjieiwiH. 

5. Chaugeij iii Ihu uizu uiid Nha|»c uf the ahilumen. 

Hrnmd Fivv. 

6. SiitU'ninjr himI eiilnr^renieut of os aiul cervix utexL 

7. Violet color of vn^riiui. 

8. Kiesteiii in the urine. 

9. Pi^iueutary tlejHiHiis in the skin. 
10. Mental and emotional phetvoiueiia. 

Bes»itles ihise there are a few residual rMhU and ends by 
whi<!h the list of get^tatiuu sigualn may he iixnpleled. 

1. SriTRFynioN or Mknj»kh. — Men«lruaiion is Hujjprested 
(Inriuj; |)rc;riianry, heeiiuse what wouhl Imve heeu mtiiftrnaf 
lihioti in the alt^ience of inipreirnatiou in now appropriated to 
the devetopnteitt of the ovuiii and reproduttive »>rj;aitH. There 
in no ovuhition during: prcjrnancy. Suppression of the menses 
IM u very thiuhtful Hitrn. InMiiiirte. ext^'ptiotuilly. ineiiHtruation 
(and even ovuhition) nuiy oe<'ur during gestation. TaRrR are 
seou^ irrv rarely, in which menMlrualiou oecurx tnihf dnririy 
prejrnaney. Suppression of the niensej^ nuiy take pla<'e fn^n 
iNiM, nuiital emotion, and niany eaUK-H other liian pregnancy. 
Atiuin, llieni^u may l»e utuivailal>U* in (■««*>< where impretrna- 
titin iM'cun* at puKerty, hefore the nu-UHtrual function in t-Mlah- 
li^ihed ; or during lactation, when it is al>seiit ; or in women 
whofH' meiirfes are waiitiii^^ from nmeiida or ilelulity. Fitudly, 
the woman lier>4elf may he untrutliful, asserlinjr that menstrua- 
tion etmtinuej* when it luw ceased for i^Vr' tTrmi), and may even 
Htnin her napkina with hlood to mislead her family. 



IG 



THE siGXs OF PREnxAycr, 



When nu'Hstruation (wt'iirs during iire;jrmnrv it fioMom 
ri'iurs every nwuilli thmii^^liniit iht- wlitOe iKTiinl ; more iVe- 
i|ilfiilly it fwwf;* attiT tlie first three or Kour rmmtliH. [|i tl»c 
latter nwe llie How if /fu/Y^wf/ to <-ome rr<ini that |)ortiuii of 
the ileciiiua vera with whieh the ex|»iiiulin^ *leri*lua reflexn 
hiiM not yd coirie in eoiit;u-t. After llie eoutael iiuiiie^l L2ikt» 
platn?. there is iio further iiitiiiHtruutiuii. 

2. (.tiiAXiJEH IN Till: Brkasts anu Nirpi.i-*. — The mrtwi- 
Miriry ijfntuh Itei'juiir tinner, hir^rer, nmre rmivahle ; their hliie 
veins more wLsily visilih-; an<t sensations of wei^lit, priekintir* 
tinL'lin;j, et*'., in llieni may Ik- no(i(i.><l hy tlie patient. There 
are also a low li;;ht-eolorc4l silvery lines ra<liating over the 
prujtM.*lin^ l)re4i:4t.s. 

The nippli-A l)«*x>nie enlar^jefl somewhat, aiui more ilistinetly 
prominent, or ereet ; and a sen)-lact««vnl lliiid uoxiiiy From 
them dries into brainiy s^-ales ujwn their surfaee. 

The arrnfa, or disk, siirronndiiif; tlie nipple ^nulnally 
heeomes darker in odor, varyiii;i with the ii)mplexion of the 
individual from the lii^htest hrown tint to hhiek. l'|»on the 
surface are seen ten, twelve, or more '•nlni'fjrd joffir/^s, whieh 
project one-rtixteenth or on(M'i;fhth of an inch. They vary in 
»ize, and eontaiu MrbarroHn mntffr. 

On the while skin JiMf omNm/'*. but immtMliately surrounditifi^ 
the colored disk, the ttrrondanj nrntln sulvH^piently ap|»eftrs. 
It con8ist>f of round, unelevated H(K>tj*, of a fiijhtrr rofor than 
the surfaee on wliieh they rest; hen<*e they are said to re»en»- 
ble HjM»t.s "produwd hy dro|»s (»f wnter fallinjr U|)on a tintwl 
8urfa<'e and disrhar;fin;: the e<ilor.'* There is one eomplete 
rttw of them plaeetl ('hwe to;relher round the dark iireola. and 
other SJiittering ones a liltle further o(f that are less disliiut, 

Srrrrtuin. of Milk. — In a wonum who hiu* never Iveen preg- 
nant liefore, thin is Cfmsitlere*! a very valualde eorrohorative 
simi. Milk, in exeeptional instances, runs from the breast weeks 
before delivery, and n drop of laet^'seent fluid may be wpieeKed 
fn»m the nipph- as early as the tweltUi wwk of ^vstation in 
some cflj*:-**. 

The dates ttt which these several lireast sijrnft appear are as 
follows: The »rrt>iiffanj nrerthi do«»» not Inyonie visible till the 
twentieth or twenty-fourth week; tlie filvmj liurn ilo not 
ap[>eAr till near the end of preffnaney ; ami nearly all the 



MOHNIXa SICKXESS. 



in 



other signs oii these parts rominence from the eighth to the 
tweUlli week, aiul iheu be<x»me mure pruDouucetl an pregnancy 

goes* on. 

H'fiat (Ifffrre of verlainly ran he attttrhpil to the bt'eaM tthjiiAf 
— They are totally uiirelinhle, takeu uloiie. In conjuuction 
with other early sij];nft they itiay lead us to fiiifljXM't tlie exist- 
ence of pre^ruaiicy. i>nt siu-h a sustpieion sliould not l)e rrys- 
tflDtzed intn an express*'*! opiniitii until more ixvHitivo Kijrtw 
ap|)enr. Their ai>Heiu'e does not negative |>rt'^'"nant'y- 

C'oniiilions rejienihlinj; them may oci-ur from uterine or 
ovarian iliwiuiet* imlejHnHlent of ift^taliou. Many of them 
oontiiiue a lon;r time atU-r Wflivery, ami might thus l>e erro- 
nts>nKly altrihute<l ii» a isupjMiwd surivedinj]: pregnancy. Cou- 
fuHion of tlii-s w^rt ariw.^ when prcguaney is gui*pe<.'teii during 
lactation, or atWr a conecsdwl or unknown alwrlion. The 
secretion of milk haj* lieen produced urtilicially. not only iu 
feiual(^«(, hut even in malo& 

In priMi}Miroai* iromf^n the (K'curreiu'e <jf the i*tcomiartf 
areola* the »e<retiiin of niilk, aud tl»e fa<*t of our heinjr aide 
to force a drop <tf hu't<*:*('ent fluid from the nip|>le, dw^crve 
great ciinsideration ; luit in mullipar:L' they muHt lie tiikeu 
CTini ffnnut mo/m. Supprftsion «»f tlie milk si-tTPtion in nurxing 
women is of iMnisiderahle. value as a t^irmlKirative ftign. 



3. MoRNiNf) SicKNFJW. — Thifl consiHtfl in nauwa, which 
may or may not he at'com|Hinied hy vomiling, on tirst rii^ing 
in the morning, or it may Like place at or after the morning 
meal. 

ft usually i»egins aUtut the fonrtli or fil^h wfck and lastH 
until the iMid of the sixt*'enlh. i>r Inter. Sornetiiiuf* it cwniert 
on a few days af\er impregnation, luid continueH Lhroughuut 
pregnancy. 

It iif a aynipathetic diflturlianee. mo8t likely due to a degree 
of congestion of the uteruH lieyond the phy?ioI<>gi4'al lintit, and 
for whieh it is. to ft«tfne extent, a natural eorre*'tiv4*. Sexual 
excitement atler conception )p prohalily a larLor in it^ pro- 
duction. 

It justilies the suspicion of pregnancy only when it <KX*ur« 
and ]>(*rsislH with<iut any other s)H*ciaI <>ausc an<l in a woman 
who is oiherwise healthy und well. 

Iu tiome preguaucieti it docn nut occur at all. 



J8 



TUE S(G\S OF PRBGSAhX'Y. 



4. MoRRii) LoNGiN^is AMI DYHi'ti*siA.~Souie pregoaQl 
women have nii iitiiKsual We^fire for j>'>ur apitUtt aii<l other acid 
fruit*, yr (.Irinks, and ttahuk pri'imriMi witli vinegar, elc, or 
there may he a liking fur stuhfiuuiees !<iill more uiijMilatahle, 
such a:* chalk, a:*hes, lime, rliareoal, elay, ami Hlal<v|»euc'i! ; 
eveu {Uitriil ineaU^ utul i*])iJers have eom|K>**t'<l a part nf the 
chosen mrtiu. Ocrasionally there is entire l4*a of appetite, or 
a (lijigu.st far partinilur f:ijlN*taiiee8. 

Hearihurn, pyr«>His, Hatulence, aud uupleai;niit eructations 
are of euriinion tHrurreuue. 

These dyspeptic :*ymptoniH aud morbid longings bejrin ahout 
the same time, and have aUvut the ^taine diagnostic value &a 
nuiTiiing sickiiehs, and their tluration is eipially uncertain. 

6. CuANuEs iNTiieBizi*: and 8ii ape op the Abdomen. 

— During the first eight weeki* of pregnancy the alnhimen is 

re-ally ihitter liiun before, aud presenti* no increase in size. 

This is <iiie to sinking duwn of the uterus, wliith ]tulls the 

biadfier down a little, and the bladder, in turn, by means of 

the ura^'hus, draws the tunbilicuH inward, t^o ihat the uavel 

and its inunt^ilintely surroutHliiig abdominal surface apjiear 

drawn iu instead of pnanincnt. Hence tlie oll-<juoletl French 

proverb : " ymlrr piat, rnj'ant it y a." 

" In atMlly Hint is liiil. 
Tlieruii (i rhild— Ik- mire of ihHt." 

But you cannot be xmr of il. 

\W the twelfth week the fundus uteri begins to rise above 
the brim of the |telvis. where it ean be fell with the Imnd over 
the pulics. The navel is still sunken. 

At the sixte<Mith we<*k the finalus hns riH'U aiiout two inches 
alMtut the symphysis pubis. The navel is no longer uniisiiully 
sunken. 

S> the vertieal enlargemetit progress*^ at the rate of about 
one and a half to two inches every four wcrks, until the 
fundus, at the thirly-eighth week, almost touches the ensifurin 
earliliige. During the hist eight weeks ihc uiiihili<'us [my- 
trudcs beyonil the surface. 

AI>oul two weeks Iiefore delivery the womb sinks down a 
little, the abdomen tiecomes less protulierant lit its up|}er 
part, an<l ap(>eara smaller in sizt*. This is generally asi^ribed 
to relaxati<m of the [>elvic ligaments aud sofl parts. 



CHANGES IN SIZE AND SHAPE OF ABDOMEN. 119 

We may more easily remember the position of the fundus 
at different stages of pregnancy by dividing the whole term 
into thirds, as follows: 

At the end of the first third the fundus rises a little above 
the pubes — say it is ai the pubes. 

At the end of the second third it reaches the navel. 

At the end of the third third it reaches the eusiform carti- 
lage, allowing for sinking during the last week or two. 

rui. 66. 




size of litems iit variouH iwriods of pregnane}-. 



By subtHvi<Hng the intermediate 8|>aces into thirds, and 
alloSviiig one-third of upward exf>an8ioii of the fundus for 
each four weeks, we shall attain approximate precision suffi- 
cient for practical purposes, f<>r there are great tlifferences in 
different cases. 

The principal characteristics by which enlargement of the 
alMlomen from pregnancy may be distinguished from other 
kinds of abdominal swelling are as follows: The pregnant 
womb is usually stjnnnetrienf in ahape ; it is longer vert tcnUy 
than transversely ; its contoxir is smooth and even; it possesses 



120 



THE SIGNS OF PREGNANCY. 



a ppciiliar t*iiff, rhiMir. rojiMittenrtf. ami may l»e felt to (*fn\traH 
unifn' imlp'itiuiu JJy careful, firm prwsriure it umy iils4i fie 
felt to rontnin a movnhh-, fltiatiiig mint hothj — the fa-tus. It 
is imt easy to (listiiijiuish these |Kiruliaritiej* by ]»rtljiati<in of 
the abdomeu. The seuse of touch must Hrst he ethinxwi by 
long praclioe. aiul even then, in doubti'ul <■«*«<, the hiMortf, 
origitif durationy aud accom}>auyh\g (tympiopui of the eiihirge- 

FiC. «7. 




ment tnti&t be fully 8tU(lie<l l»efore we cmi nttach l<» llK-rn m\iA\ 
iUli<riiustir iiii|X)rtatir('. 

Mrthoil (if Exnminaiion, — To nst'ertaiii tht- Aic uiitl other 
rharacteristif's of the gravid womb by jialpaiion, either the 
moile of nmni|niIation already nientitmiMl un<ler "ijiiieken- 
iug" (l>ft^^ l**"^ * "iny ^>c used, or <nie Imnd inny be placed upon 
the abdomen, a;* shown in Fip. 07. In tbu* illustration the 
left hand is used, the examiner standing to the right nf liis 
putieut. The bund va curved to Hi the eonlour of the uterus 



OS A^'D CEIlVrX: SOfTKMXO AND ENLARGEMKyT. 121 



and ulatvd, at firnt. low tIo\^ti over the hyiMipwtric region, 
luteriiiilteiit |ir«r»ure in now made, mid during'; eiirh iiiterndt*- 
sion the hand Ls cnrrieil i^raduully hi^duT U|i, the [irt^iiro 
iH'in;; f:reater at the vhiar border of the hand, sti that wlien 
the fundus of the wohjI) iii reaehed the hand at once ret-oguizea 
the diminished resistance and aiuka deeper Liiio the ahdouunal 
sjmce alK)ve the uterus. Deteetioii of tlie eidar^ed uterus '\a 
easy late in pregnancy. During ihe earlier months, when the 
tumor it! not well alxive the pelvic brim, it i» more ditticult. 
lu th*«e latter eased let the lower lind»s of the woman be 
exlentled and slightly separattsl ; then pUce Itoth han<!H Hat 
upon tJH' aUlunien and make ettntinued firm prtvMire while 
the woman Uik*.^ several deep inspirations. Durinjr the conse- 
quent expirations the resistimce of the, abdominal walls will 
fiDally yield, and the hands lie enableil U^ explore the region 
of the |»elvic' brim and demtmstrute the enlarpe^l woinh. 
Beware of inijstnkinjr a dist^-mled urinary Madder, or one 
whose walls are hv|>ertrophied and in a state of i-on trad ion, 
lor a contnu'tin^r pregnant uterus. Fibroid and other liiinors 
of the uterus; ty>tic ami other Himors of the ovary; disten- 
tion (tf the wondi from rutuined menses; aecumnlalionb of 
fluids or gases* ; ol>esity ; iiseudwyesis : enlargement of liver, 
spleen, mid other of the alHtuminal viseeni, et<'., may li^ad to 
enlargement of the alKlomen Himuluting pn'gnaiuT. The 
hist/)rs' and duration of the swelling, t<»gether with ac(M>mjiany- 
ing symptoms, sliould prevent its being mistaken for gestation. 
(SSee liiH'erential Diagnosis, page Iji."*.) 

(». SoiTKMNt. ANI> P^M.ARdKMKNT OF ()s ANI> C'kRVIX 

I'teri. — In making a digitjil examimitiiui /« r nn/hmm the 
diH*ereurt« to l}e noted l>etween a vinjiu uterus and an impreg- 
naii»»l one are very oharaeteri.stie ; but between the impreg- 
nattsl ami unimpregni^ted uterus of a woman who has already 
ix^rne chiMren the dirterenees are lewi marked. 

Seareeiy any elmnge takes pla<*c* dnrim; the tirsl few weeks 
of pregnaney other than the alteration of |Hisition in the v^ondi 
alreailv noteiJ, together with inereiis^^d weight and eonsefjuent 
dindidsluMl rmdiility of tlie or<ran. 

The ehief ehanieteristif of the virgin eervix nteri is /fn/mrM 
of rousisteuey. Very s'jon at\er impregnation it Iw'gins tv 
itoj'irfi and enlarge circuuiferentittlly. The lips of the os ex- 



122 



THE SltiSS OF PREQSANCY 



Leruuni lHM'<»mti wider iind puHy to tlie U>uch, aud the H^tsure 
of the (»s liecomeii ri)Uii(lLT iiiui larger. The Hofttiiiinj; lie^ns 
ut (he ouUide (va)j:infil jiuHiuiM auil ht\Vi->l part of the cervix 
iiihI gradmilly i*xtt*n(is upward ainl inward luilil the t<)iM|iiu*l 
mnluie of the viri;in tvrvix is cniiviTtt^d into a s(il^. elastic 
projet'tioii whune h-n^lli is afif/itrriftftf shnrtwu^d liy incrtjwe of 
width aii'l diiiiiiiiKhfd n^iHlaiice to tlie fxaniiuiu^^ liti<rer. 

Thfj*e flmiiges' begin simii after (xnn-eptiou, but c*c'ar<*ely l)^ 
come eJbJy t»f recognition till alvoni the tillli or nixlli week. In 
iiixtoen weeks the A'/w of tlie i« are soUene«l ; iu twenty weeks 
hitlf (hi- ptrvix 18 sort, ami the whulf of it law undergone the 
tiunie chtuige when the **t«rni'* is uithiii a month uf c«>iuple- 
Uon. 

Arter one I'hihl the n-rvix never goeti baek to its pristine 
virgin firmness, nor fh>es it recover the ])erfeet snuMtilmc-:** oi' 
Hurface and Hmallnefls uf the extomul its eharacleridtic uf the 
virgin uterus. 

Again, during a tirst pregnaucy the os will not aibnit the 
end of H finger; during a Hul)MH{ueiit one it generally will. 

The (litKjtiostlc iHtluc of Mtfi/'uinfj and rnlartjement of the 
rerrix ntrri is oidy relulive ; their iiLnrtirr would generally 
nt'tfaiirv athftiirff pregiianry ; but as they may <Mrur from 
ttther e3iiis(>s, the normative uvidencit the.y t'nriiisli is tu»t 
rebable. 



7. X'loi-Kr OK DiTSKV ('oi/>R OF Vauinai. Mi:<^>rK Mkm- 
JIRASK. — liy flacquennn (who iirst *liseovered this sign in 
examining the pntstiluU^ of I'liris) and oHii-rs, it Iuls Ihh-u 
considere«l to furnish [msitive evidence nf pregnanry, ej4|)e- 
oially during the early months. This is an error. The dis- 
coloration is due to venous eongt^tiiMi, and (Mriditions <'li>rtt*ly 
resend»ling it ituiy iK-cnr from uterine or vaginal congestion 
inde|»endeul of pregnaney ; as it nui only be observed by 
iua[>ection, it \b not ulwayn availalde. 

M. KlKSTKiN IN THK rm.vic. — When the urine «»f a preg- 
nant woman is kept for some days (it minf retpiire weeks) at a 
tem[)emture of alNHil 70° F., a Hoeeuleut, wiH>IIy-lookingeIoud 
liegins U* fonn in the centre of the liquid, which gradimlly 
rises to the surface, like a [wllicle of grease on cohl bn»lh; 
and, later, the film breaks up and falls to tiie bott^mi of the 



mays vuniso kacu Moyru. 



123 



YttftM;]. ThiH Ih kit'^iUnn. It iH-c*iirti t'rotii the eighth week tu 
the !hirty-i*eo>niJ, or lherealM»iite, ami then ilisajtpcars. It 
fuusintrf of a "|iroU'itie Hlll^8tnn^^^ tri[ilt' plu)S[iliiiU-s, fuii^ri, 
uiiil iiiriiHoriii" ( LuHk ), M> ulU'U SLi'ii iti 4]el'oMl)l()^^'lt urine, an<i 
iit oJ* little (liagiioHtir value, iiia^iniK-lt ut^ it (Mrurij in the uriiiti 
of uien uud uou-preguant wouieu. 

9, Pi(;mkntarv DEi't^ns i\ tiik SKiN.^Hwticlfa ilarkeii- 
iiig of'tht' areola oC the ni]»|ilei* liefnre nn'iitioned, there is iMt-a- 
Biormlly u hruwu, iireoluus bhisli nroiuid the iiiultilicuH, wlitrh 
uiHV extern] aluii^' tlie jiieiliau liiif t4t the puW. It vurieii 
with the eoinplexion of ihe |)iitient. In rare litMuneeH the 
rohir euvere the whole alKhmien, and (■««« are rec^mled of itif 
flprcadill^ over tlie entire inxiy. 

Irregular {itttehefl of jii^iiieut (ehhuixntuta j also unjK'ar on 
the faee, with dark riniLrs under the eyes. They disapiiear 
after delivery : sonieliinen sooner. 

10. Mkntal and Emotional I^iiknomkna. — A markwl 
change of teni|»er in the wonuin, nii fn>in aniiahility lo peevish- 
mwe, from eheerfuhit-^ to rueluneholy. ete., or e?(aelly op|KM^ite 
chanpei*, may tieour. In some wmtieii the murtii 8<*ii^e is 
depnived or elevatetl ; and iutclUtUutl jMwer nuiy Ik) nnHliiicd 
ill de^rree. 

The«e aijrnn are oidy of r<»rroliorMtivp iiw in dia;:n<wis. 
They are v^eiierully more apparent to the liouKehnJd than to 
the phyMieian. 

AlMHTioNAi. StcNH. — The fo!|n\vin;r additional si;rnH niny 
iHMioted : TiMilhache, i>r fmial rienraliria, ftr iifinal earit^ of 
the teeth, durinu Min-ei'j<Hive prev'tianrit-:' ; Milivulion without 
mercury ; a tendency in Hvn{H)|te in wona*n not difi|M»t*e<) to 
faint when unini)iregiiate<i. Some women date itnprej^nalion, 
niul otten ciirreetly, from nnuHual };nttiHeatioii during: a jiar- 
tieular act (»f ectition. 

The inlriMhuiion of a clinical thermonieler into the cervix 
uteri is Huid t4i indicate an elevation of t<'ni|ierature { 1*^ or 2°) 
when prejjnancy exist**. 

N»»ne f»f thcHe itidi^-jitionH nn^ reliatih*. 

filiiNS DrkiNo KArii MoNTli. The dillerenl Hi^^'us rt*C4>g- 



124 



tue: signs of pregnancy. 



V 



uiuiMc iluriii}^^ the (litlt'rtMtt lunar inontlm nmy mwist thr ol>- 
Ktetrman in jutl|;ing the diiralion ot* nii i^KiHtiii): [iri^iinucy 
aii<l prohiiliU' <lat** of (iclivery. They are a** t'olI(twri: 

Firxl Lunar Muuth,- — Ai»w*nt iheurie». Ga^-tric anil iimm- 
ninry sifriiH nmy, rarfly. \k"^\%\ thus early. Tip of cervix 
lH*>riii« lo w)rtt?ij hy enti of nintith. Slit of the iis more eir- 
cuhir. Uterus sinks, rnihilinii^ «ie|>re«*etL 

tSeromt Mottth. — Mniniiiiiry and ^untrie mjrnn uHualUj hopin. 
I'terUH HinkH ; hy[Kipuitriiini slijjrlitJy thiL; uinhilieiut depr^'S.sed. 
SotVeuiu^ of cervix exK^ndin^^ hi^lier. Menws HU|i|trtsfletl, as 
(luring reniuiiiing niunllui. Hegar's si^u iiereeptihle. 

Third Moiitli.^-i oiwtric syni|itoniH eontiriue ; nianininry sipns 
incrtJise. Wonih Htill sunken; <•* low in vajrina ; navel still 
hollow ; hy|»c>iriLsLrinm 8till tlatteutH] ; |^^lt;^f^essive t«)ftening 
of tw and e^Tvix. At /mf of this month W4(inh hepins to 
rise al>ove hrini 4if |K'lvis, with conseijuent hi^dier poniliou 
of (;ervix au«l \vm Haltening of alMionieii aii<l sinking of 
Uttvel. 

Ftjurlh Month. — CrflBtric 6ynipti>nifi ciPinnKiiily Huliside. 
BreaM sijrns further develop. <_4Hitiruie<l MHcerit of uterus, 
heiut» cervix hi|L'her in vagina, navel U^s ht»llow, alithinten 
less tlat, or hepnninp U* eiilarire. Fundus uteri liy etui of 
this month is two inchet* alH>ve pidn-K Pro^^ressive tiottening 
of cervix. Women imnj **feel niolinu*' Inward cimI nf the 
month, when .^killed examiner may also det<M't hallottement 
and intermitleut contractions. I'terine wmlHe audihle hy 
stetlHttMone. Very nt^iite hearers rinim to luMir heiirt-Kouuds — 
vi^ry iifiUKual. 

Fiflh Mouth. — Hreast si;rns increfise. The "wnimdary 
arw»la" ap|M^ars. (^iiiekeninjr conmionly oecun*. (laslrie 
symptoms entirely relieve-], llallotlenieut eiisily re<-o<;nized. 
lleart-soiuiilri niiilihie. t'lerlne murmur. (Vrvix seller, and 
uftjturrnt >iior(cninK hejrins. h innliis nii<lway iR-tweeu puhes 
and navel. Alulufnen visihly enlarged. Ihnhilical ileprea- 
siou diuiini^'hed. 

Si.rth Month. — I?allott<riieiit, heart-soutids, ft vial motion, 
and uterine st>ntile more distinct. Lijwer half of va^dnal 
cervix softeiiwl. External os may just admit tip of tinjrer 
by end of this month ; this ilouhtful in priniipani. though 
just |s»s«ihle. Breast si^jiis and *'»e<*ondary areola" increase*!. 
Uinhilieal depreMiou almost eHaeed. Uterine tumor distiucL 



DIFFERESTIM DTAOSOSIS OF VHEa NANCY. 125 

FuuUus up Ui iir just ubuve uavel. Afifjarcnt ubortvuiu^ ol' 
cervix inrrenwd. 

Si'i't'nth Mtntih, — HiillottoiTiPiit nintitmcvs: iiiis^'ijUatorv si^ns 
still more iiiiciiU!**. Fumliis two irirltw* hIhiv** iMiilMrnMi.s. IH*- 
prfiwion of tmvol wt'll-iii;:}i itr ijiiile etTiU'***!. V:i;,nrial cervix 
appttrrntftf rediHvd une-liall* in ieii]Lr([i; lower t\v»»-tliinis of it 
si>ileiie<l. (Vrvix still liii^luT in viiiriiiii. Hrtsist nitjiiH iii- 
crearteil. Kxtenial lw may uiliiiit ihi^vr-ttp even in primi- 

FJijhth Mnutlt. Hii\\t)lU'-tm\\\i tUmUxM ; othpr phvsirttl si^rns 
more iiu<iible. Greater [wirt of cervix Bott, ami *utftjnii-fnt'* 
ghortfiiiui; inrrejised. Ahdomen distemle^l, nml distinctly 
pyriform in i(liii|>e. Umbilical ileprt^ou ^t>iie. Fumiu» 
midway between navel and ensiform cartila^o. ()s hijrher 
and diliicult to roach. Rreant rfignH increased ; milk uuiy 
Iw secreted in some rpiantity in mullipane. L'mbilicua may 
bei^in to protrude toward bust week. 

Ninth M<niih. HrtUotlenient alweiit ; other pliVMinil si-jTiis 
more distinct. Umbilien.s protriid*::* beyond sndace of aUlo- 
men. Ftindim Btill higher than \t\Ai month. Kxternal tK« will 
easily admit finyer-tip; and, in nmliipane, os and wrvix will 
admit Hnger to feel f<Ttal head and mend>ranen. liijw <>f os 
thick and suit, and apparent shortening of cervix rapidly 
pro;;re«s?iit. 

Tenth Mmth. Heijrht of oh and fundus anil protninenee 
of umi>ilicus reach their maximum about middle of month. 
and then het^n ti* lessen. Cervix ulnri ob]i(erate<l by rctif 
shortening during thirty-ninth and forlicLh week- !/i|is <»f 
08. in primii>anp, become thinner ; in mtdti|tara\ retain more 
thieknei!«!« till the end. Prertentiug |>art low tl(»wn. ()j» uteri 
easily reached. Physical si^ns dwlin4't. SymptiJiuM due to 
pressure disap]>ear. There nmy l>e o^deum ni' leip and j^ni- 
tals, with pain and difficulty in walking;. 



DiFFKRKWTTAL Di AfSNOSW OF Prkonascy. — FromOmrtftH 
T*im<)rA. — In ovarian tunmrs (cystic de.ircnenition of the tivary ) 
the ixwitive Kij^ns of prejrnancy fire aliwent ; menj*truation rfrn- 
tralip continue:* ; there in fluctuation ; hidlitrv of tumor shows 
It l<i be of loniTf^r duration than prepiancy. and U> have l>e^mn 
on one eide of the aUdnnien ; cervix ut^-ri not ^>ftene«l ; womb 
Dot ealorged, aud can 1)6 movc<i without moving tumor ; or, 



126 




THE SrONS OF PIIEGNANOT. 



when tumor Ls riill('<l to oni* nido by alxIotiiinHl fmlpatioii, cer- 
vix uteri (l<M'i< iHit |):irti<'i[mte in the rnitvenient. :i.s (lemoi).strate<l 
pt'f fa/fin(tm. W'lioii tlu* tirnmr is Inr^jo tlierti is fMiuiciation, 
i'S|K'i*iiilly oi* the tmv, and fniiure nf the general he»lth. Kx- 
t'Cjktioiis to l>e Iwrne in mind, e. tj. : 

Preirnartcy and ovarian tinnor rnay (tH^xiFt, when ah(h)niina] 
j»alj>ali<jii will revt-al two tumors of ditTfrt-nl consisNMK-y, with 
a jHJi^^ihle t^ulcuH lietwtHMi them. L>ia;<iiutti,s difficult, H!t|»ei-ially 
when iiHSuciatfHl witli dro|)ny of anuiiou (exfosw of liquor 
lunnii). In the InthT ilu«*tuntion is more «ii|)r'rtirinl ; cervix 
uteri enlarp'd and w>n(nK*d ; wundi finm nu»v«' with niovi'meut 
of tumor, \i\jor haviiij; rlofided to oiK-rnte for ovarian liimor, 
tiliouM any lin^rerini.'- dtujhL rtiumin uh to |jre;rimn<-y, Ihti wtnnh 
may \h^ mwusurtHi hy tlu- uttrine jMtumip or the os dihited to 
mhnit exarninaiion hy tlie linger. 

The practice of a.»*|)iraliuj: some of the Wind in tht^io ca«!S 
for examination has hee.u pven up. There is no luorpholoj^i- 
cal or ithemicul elemeut iu uvariau tumora hy which a diag- 
nu«ii4 could he made. 

From Flhroid Tmnjtrn of Uternn. (Fibrous lumors» Fibro- 
myomata. ) — In uterine JihroidH. tumor U (o>m|>i»riitively | 
harder and nvore iiichuilic; if is nusymnietrirui and n{Hiuhir in 
outline ; of much shiwer ^'nmth Ihan prt';rn:uit woruh ; i* ac- 
companied with profnse roonslrnation ; cervix not Bofteneil, 
but Muiy he unevenly enlarjred. Ponilive HijrnH of prep- 
nancy aK«tcti1, allhougl) the uterine s<jutile may Homellmefl 
l>e heard. 

K^irely fihntitl-* may c(»exi»t with prepnancy. DiapnoMH: 
by phyjiical .^^i^rns ni' pregnancy an*l tcjiiiIIh of time, J^Uir 
will ciMue otu and riniy terminate naturally, providt^l tiimur 
doe:* not ohstriK't jK'lvis. 

Fttnn DiMfi'ittion of ilfrnA dur in liviahini Mrimrn — Ihnnn- 
tfimt:lrn. — In retention of nwnsie.'* there i}» a hi.'»tory of pain at 
ihe nienstmai pcriod?i ; uterine tumor j_'rowH hy sudden cn- 
hiriremenl at ea<d) jieriod, with Home decline iu **ize al\erwjird. 
l^l^rus more tenso and resisiinij than in pregnancy. Va|,druil 
examination reveals mwluinicui ol>struction. either in vagina 
or uterns, prcventint: e;Lrrej« of mcns<>s — this may be conpeu- 
itiil. or ac(]nirp<l an ret^ult of inflammation. adhc:tion. etc. The 
breast sipns ami jnwitive siijns of prej^naucy are absent- 

From DiAlmiion of IhertM dvc to Gas — Phymomfira* — This is 



* 



* 



DIFFERKSTIAI, DIAGNOSIS OF PRKGNASCV. 127 



really a tympaniirH of the uterua. The pas, retained by Rome 

olnrtniftion in the cervix, is due io (Iwuniposilioii of niatlcn* 
willdn the uterine cuviiy. Wonili eultirirt'i* mure sfotrhj, and 
t*» 11 ifAi* riftjter than in pn-^nancy. When lar;^'e enou^'h lu he 
percussed, it i:* n-wiintiL When lirte<J with the finjrer, per 
iwfhiani, it \» li;^litcr in weiirht than it>t tn'/x-. wnnltl inilicatti. 
FetitI pis may e«*U|»e from the vajxina. I'uhilive Hijrns uf 
prt'L'iiatn-y ul)^^ut. 

From jUMfuiion of f'trrn/f due fft Wati'nj Fluid — Hifflro- 
mrfru. — Tin- lluid iwcunnilMtei* in the nlerinc cavily, ewitip lo 
«hsirueti(»n in llie ivrvix. Womh whhim lar^'iT than an 
oranjje, and ^row.* j^Iuwly. Mt*>i apt to iK-cur alter "clint'pe 
of life." FiurHuUinn may he ileteriisl. Al.s*'nee cf positive 
8ip»H, Hydromtftra and phywinietru are extremely rare. 

Frfmi Obesity. — In eniarpenieut uf abdomen from fat, other 
|»irtjt of the Uxiy are enhir^'ed ; belly Ih w)U and 4louf:hy to 
tourh, and without any central (uterine) tumor. The pnr*itive 
aijniK of pnynaney and nxtnt of the siiriii- about tliK hreaslK, 
etr., are aWnt. The rtTvix uteri renjnius puiall aiMJ \in>oll- 
eneti. The uterus itwlf is uot iuereaseil in eize or weight and 
retains it» nnnal moliility. 

From AlMhnn'imil Ihojun/ ( Aixritfj*). — In dropfty there is ilis- 
tinet fluetualion and no uterine tumor. Kewtrium'e on pereus- 
siou of alHhmieu ehanges itH Imumlary line (horizontally) by 
ehanpn;: pi»9ition of woman, owin^r to floalinjtr of inteflineH ; 
eervix uteri nnfhan;/e«l ; pi)ysie»l hi^ih of prejruanrv ahseut, 

Frtmt Awrnorrtuto ttJtjmriatttf uith Coufitittivf Eitlnnjrmmt 
of Crrrir / V#n". — This isace^imiMinieil witliHymplfniihof uterine 
inHanimntion ; backache ; jmiits in ihr hi)>H, abdomen, ctr. ; 
weijrhi in perineum; dirtimlty in walking'; and, on exiiminn- 
tjnn, the cervix uleri it* liMulcr to tlic touch. Time will clear 
up doui)t. If prejrnaney exist, eidarj^emcnt of iht; bodif of the 
wond> will Boon declare it^ 

From iWndonit'iti/^, — This means " fabe " or "spurious 
pregnancy." Women who wtnit to Ik? pregnant, and winjzle 
women having: reart<»n t<» frar pro|rnaiicy, are apt to iningine 
thenisclvcj* rhdfutc when they are \mL 

It ofTurw mof*t often near the "chancre of life.'* when ce»wa- 
lion <if the men*;*',**, oln^ity, (ympanitet*. and varimiH sym| a- 
thclic phenomena a|i|)i'ar to k'ud color to tin* fal?e inipr<>j*it>n. 
There are hysteria aud iuvolunlary prujecliou aud euulraction 



I2S 



THE SIGNS OF PREGSANCY. 



of the HiKlnriiiniil walls, n^iiiiiiliUiut; tlu* eiilar^eil utMiilt iiud 
fiPUii niovenicnti*, H^walle*! "phanUmi lunwr." 

Uia;rii<)t4ir< : iiii;ivL)m<in liy ether at (iiitv (liK]ierMv the uIh 
4loii))iial si)y^n.s, ami vii^iiial exaniinution revcaltf nil um'ImugtHl 
riTvix wWr'Xy ami an cniptv, iiinMihirLtil utrriis. 

Front TifinjMiniit'M. — Tviiipanilir dist^ntioii of the alMloiiieii 
^ivi^s tynijMiiiilir rtw>nnrH'*' on ]HrriiHsioiL Pliysi<*al it'iiiiw of 
|iri';:iiaiicy aliwiit. lUeriitt not I'lilurjri-iL Tviii])aintiv aiui 
lirpjrnaiii'y inay ((M-xirtt. Kxrlmlc (Ih* hiltiT hy luakiii;,' mtt- 
tiiimjiiH tirm (tri-Hfuro \i\mu {\\v alnl«MiuMi during' wvoral kuc- 
fcewive re--*jtinilii)i»H, iurmiJiitirj thv ]trt^?wure during the expint- 
t<»ry acts until tho exnniiniti^ haini.s— *jne plmvij u|»in the 
(Hhvr — fei*l the spinal nilninn. iinti llms ilcnunolrale the 
iilist^mv of any intorveninjr enlurj:e<l uonih. 'V\w. alMhaninal 
imlarjjerrH'Ml of prf;;iianry is (Miit'tly in an antt'r<H|«»*t<.Tior 
direction (iurinj^ the early iiiontliH — not from nide U» side — 
while in tynipiinilw* it is in IhKJi and all din.H*tionK Normally 
the fohlri of intestine remain alxive and liehind (he nit^riw 
during; prcirnancy, heui^o there shoidil Ue \m resjumnee on |>cr- 
cu»f*ii>n in front of the womb; *»nrh rewnuirn'e, however, otx'ure 
wlien tlie tympanitie inte«tine i.s iorced In'tween the ut^rns and 
ahtUmiiual wall tiv ibt own dinteiition with ^hh. 



METriioiw AM> Orper of Examination. — In exanduiiig 
a woman for siisiKM-twl preirnancy the order of rtequenee in the 
several stejifi of the examination nhcnild ]k^ lus follows: 

1. Oral examination as to hitttory, syinptoiim, and duratiou 
c»f the ciiM^ 

2. ExamimUion hy (ti) i])H[jeution, and (6) }>al|>Jition of 
hrearitjt ami nippiest. 

8. Exandnution of alMlonieii by, pui^-ttwively, ins|)ei*iioii, 
|Kilpation. )ker(-ut«sion. and au!$rultatioii. 

4. \'a;:inal examinati(»n : {n) ili^ital, (h) In-manual, (tr) hy 
im^ftt'rtioit if itrrr.Mintry* 

'h Dij^tal cxaminaLioii, per roctuni, if requircnl. 



HYGIESE ASD PATHOLOGY OF rREGNAA'Cr, 12» 



CHAPTER VIII. 

HYOIRNR ANI> PATHOLOGY OF rRKGNANCY. 

To aDticipate the palhoiogical phenomena of pregnancy 
without stiqiriso wp Imvr rmly lo rocall the pb}iitio/^(fii\tl 
rhanjrt* thai inii.-tt net<«w» ri I v take place with everv jfi-nla- 
tion. Frocessfs of chamjf — of structural evolulioii — whether 
pn)j.'rif«ivr or rotro^rt-Mnive* and whi-thtT wrurrin;; in inuiif 
wouian. nr rhihi. are utumjit liahle it) Ik* intiTrnpUHl l>y slight 
(liHturUing ('iui;4c>.s, and thiLs develop jtatho/injiral phenomena 
of more or lesw gravity. The phyftiolo^rieul ehan^es incident 
to pregnancy arc without a parallel, in their decree, in their 
uiiml>er, and in the rapidity with wliirli theyofcur. In a few 
months the uterus increase* in Jti^r (from 8 to 12 iiiditv in 
lenj^th ; from li to I) in width ) ; in ncifjht, from al«*ut an 
ounce to al>out two |x)umla, not including it» contenlH. The 
CBpucity of it» t^vity is enlarfjed oiy timra f Lusit, after 
KniUDe). The area of itin external surface is iiirreitm.Hl from 
l(j ^nare inches to 3;il* grpmre incht*. Af/ of its ti.**ne8 : its 
mnaeles, ligaments, arterieK, veina, iympliatics, nervea, and 
norve-panplift, he<»nie trt^nendously hyttertrophieil. The 
uterus itself chnnjrei* its jtoHifion, pr(da|winir durinj; the first 
two months, and L'nidimlly rinin^' arter the tliird. Later on 
fow'in^ to diMtentioii of (he rtnlum and Hi(;moi<l Hexure of tlie 
(Mdon ), it hoi'onieri twiKte<l tui its hm^riiudinal axi^ s(» that its 
anterior asfs^t Kfokn Noiiiewliai towards the riclit, which hrinpi 
thestnniiir*'s in the lcl\ hroad lijranient more to the front, and 
tilts the fundus a little towanls the richt side. Correlative 
chancres in the niMhmiinal walls, and in the position of the 
alHtiMniual viscera, must also «H*Pur to aivonmiodat'e the eu- 
Inrvevi wtanh. The vairina and vulva undergo a somewhat 
similar hy|H'rtro|diy, ihoujrh le«< pronounced. Chaufx-s also 
lake place in the folds of |S'ritoncuni nnd conne^'tive tisnue in 
the |>elvic cavity, as well as in the lipinienta, i-artilu^eM, and 
Jftints of tlie |>elvis itself. At the stinie time the nianimary 
irlandri arc ipiictlv ^'-oin^ through a hy|»ertriiphic evolution 
prejMiratory U* ladation. 

Willi tlicM* ItM-al phenomena nni»t iiei*4*ssarily take phui:* an 
extwmive nKslittcation in the treneral Hvstem of the wumau. 



SM^ 




130 HYGWyE ASD PATHOLOGY OF PREGSAiiCY, 



es|)eoially with refvrenc*' ti* the general nutrition. JShe pro- 
vider the nutritive pahuhiin hy which the prowinjf urgan^ are 
au»taine<i, ami hy whirli the fcHus, with it« a|)|)endDfres aud 
bap of waten«, is Imilt up. Slie ninj^t therefore form more 
hliKHl, digest nnir«* foitd, nn<l inrTenf^e the activity of her ex- 
creliup am! secreting organs. The extra hlo*jil inuHt he prop- 
erly circulated, not only through the liy|»ertro|)hie<l vesseb* of 
the enlarged repnxluctive organs, hut also through the pla- 
centa ; hem*e, in pregnancy, there o<*cur!*, iii>rrnully, hypertro- 
phy of the lert ventricle of the heart, which disuji|»enrH aflei 
delivery. The eliniinatiou of curhon dioxide hy respiration is 
im'n*aHed. In short, the pn'gtiant woman has to provide nutri- 
uient, to hreiitlie^ (o cirrulnle hlwid, to wecrete and excrete, for 
two individuals — herwelf and her iVctus. 

The HUHjjeiwion of ovulation and menstruation during preg- 
nancy con.slitiitc furtlier changes of fun<ti<iii, which, while 
natural etniugh, nniht add something to the expenditure of 
vital force. 

With these varied ami numerous .*itructural ami functional 
ehangt^ and with the necesHary increa*4e of work imp^jsed on 
the general nutritive system of the pregnant woman, it in 
warcely to he exi>e<'te<l thai gestation, espn-ially in women 
whotse lives and habits are artificial and untmtunil in many 
resipeot*, should l»e altogether hiiruf and free from unpleasant 
symptoms, if imieeil it be unaccom(>anied with serious dieeaae. 
The wonder is rather the other way, viz. : that suffering is not 
greater and diseust* more frw]uent and severe than we find 
them. It may l>e well said : to breed easily is a gtKtd test of 
Iwdily sound net**. 

The abnornml surn>undings and habits of pregnant women, 
especially in highly civilizetl comniuuities, are more account- 
able fr)r sutfering and discomfort tlum is the pregnancy itself. 
Faulty hygiene, either from rnreless negleii, or ignorance, is 
often the real cause of disaster and distress. To pres^-rve 
health is easier aud better than to cure disease. With this 
view the following directions will he of service : 



^ 



HvfUESK ANi> Mana<;i:mknt ok Normal Pregnancy. — 
Let every pregnant woman breathe puri' iiir; hence the atnioa- 
phere of the country is better than that of a city ; out-d*jor 
life (climate and weather permitting) better than indoom. 



HYGIESE AM> MAyAGKMEyT OF PJiEaXAycV. 131 

Rooms to he well ventilated by having one or more windows 
tlowii. eveu ever so little, /rr/m (lif top: iitinoMpherie imimritu-a 
Uiiiially aceumulate towartl thr rfUhifj, C'rowilt'ii aimrliiient:^, 
theatr»t, ehurdies eXv., nliuuld Ite iivuuUhI. Mmiy pregnant 
women !>eciJine |*e<'uliarly seiisitive to disiij^reeHble (xlurs f hjiftft' 
osmia had l»eeii iK>tiee>d an one of the si^ni* of pretrnanry ), iis if 
iiAture bad provided thein with a s|>eeinl iur^tiiict to detect and 
eaifjijie infet'tetl atonj^ipherts*. Throujrhout pre;rrmDey the 
eUiiiiiiatitm of earltoiiic dioxide i.s iiKTeii.Hed alKiut 2-J {»er 
eent., and diirinjr the latter nioulhn llie enenHwhiiieiifof (he 
enlarged uterus (owurd (he diuphrifi^in iiii})edt« re>piratiou ; 
beiK% pure air beetuues a prime iieev?*'i(y. Unroriuiiately, 
rfspiraiioM in further restrirti-il liy <//7>vt (notably con^tU) and 
()y muArnlnr iudolrnv.e. (_V)r>elH nhouhl Ih^ dir^canled iiUo^elher 
durin^r the hUer months or worn lot»j*ely, or, if |>er?*i:*te<l in, 
thuir *'rilw of Hteel" should l)e interruptcul with hjiuina* of 
elnstir fabrie — a methoil of construetion coniirioidy provided 
by Hlnyninkers for proirnant women. Avoid wnist-bandn and 
girdle* rrmnd tin* al>donieii ; let the wei;,dit of skirt>* Ih.^ »\x\h 
(lorted by »iiisj>eiiders from the ^houhlers. (larlen*, whether 
ulK)ve or below the knee, may prmlure (»lemn of the feet and 
varicose veins in the Ii-ir. An»ong other victv of ciwtume are 
high-heeled hIkhv, whirh impede loeiwiiotion ami pnKlnce 
stumbling;, with it.s sometimes* <ii«\strons c^jnserpieneeft. All 
clothing shoidd be eomfortubly warm, the lower limlw ei\ye- 
oially being prottvted from cobL Ex|)Oetnre to tidd and wet, 
e:<po<;ially when over-heated, may lead to reual eongeistioii and 
iie))hritis. 

}fiiAriihir J'Jrnri^ir, The bi-st exen-iiie for a healthy preg- 
nant woman, eveu up to the day (»f her l^niiir-iii, is tvnikiug 
ut fhr oprn nir. At no |M'ri<Hl of pregnmn'y iiee<l it Ik? in- 
terdicted, if kept within the limit of moderate faliiriie. It 
iuereasea^ rtypimlion, ap[>elite, and dig^tttion, and promoter 
sleep. Violent exercine and mu.s<.*ulftr strain of all kimb?, 
ee^HM-'ially litlitig. miuit be nvoide^l. Riding on horseback, on 
bicycles*, and in vehiclt^ without sprinirs over rough roads are 
injuriotit4 ; jter ttmtnu oxereis** in simnttldy running ('Mrriii>:e» 
U(jon b'vel nuuU is fidvic>ahle. Much de]>endH U|Min the 
woman; one may wiOmtand alrni«t *'very sort of joltinir and 
rouyh ni*am' without any ill ell'iM-t, while anothpr — more 
tiervouti, <U'lifiit«, and excitable — will suHer, »*veii to the ex- 




132 BYCrKSR ASD PATHOLOGY OF PRKOXAXCT, 

trenie of a1)orlion or prenmture labor, from very slight nie- 
chauit^l (lifiturlMiiKrea. Uft« t^re in all. IiiV!ln>ad ami street- 
car travel may or may not be injurious, at the oiechauioal 
jarring i^ great or small anil the women more or \vs6 excit- 
able. They should be avoiikHl during the last few weeks of 
prcgnanry in all en>»e». No pregnant woman who is eubject 
to fieii-sickne«* ;*h<tuKi risk iM-eun tnivel, and those who sutler 
ill the iMime way i'r«-)iu the swinging of railway airriages should 
not tnivel by rail. One great virtue of otttHli>or exereise 
is tu Ufvert the woman'H niinil from dwelling uyum her eom- 
paratively IriHing ailmonts and magnifying tliem into horrors 
of infinnity, with a liability to t\r\i\ mUi ehrouie invalidiitm 
and hynt^'rin. Let her l>e iH-rsuadeil to n«iist languid lolling 
upon her eoueh and !4ei>k rHVisliment und exhilararion in the 
Huu and air, provided, of course, there lie no real cjudition 
retiuiritig rest. 

FooiL — There 18 no reiuou, as a rule, why a hrnUhy preg- 
nant woniun should make any great *'hange from her ordinary 
diet With frc^b air, exerrise, mental divcrsitin, and free- 
dom frtun the [ueelinnual pressure of c<)stume, her apjjetite 
and digestion may \\e good during most of her getttation. 
Motlerate moniiiig siekuews may interfere with her first daily 
meal enrty in pregnancy, and the growth of a large nt^nw 
eneroach ii|miii the stijuiurh during the later nmntlis. but 
in spite of tlwiN' drawbacks most Wimieii manage to Ms.'^imilate 
enough fiXMl to gain flesh find improve their general nutrition 
rather than otherwise. The wnmnnV tastes — her likt^ and 
dislikes; — may usually lie indulged with advantage, at least 
in so far as they refer to ordinary foods. Wines and altx>- 
holic drinks* together with ten (which eonsti|>ates ) and <x>ffee, 
shoulil be taken with great modemtion, if at all. Kipe fruits 
of all kinds, an<l driinl fruits — notably pruut^A, of which many 
pregnant women hwvime fond — are of service in correcting 
constipation. Wliile milk imd chocolate nmy l»e taken when 
desired, the one drink — wv^X inifwrtaut to every function of 
the body — which many woni*'n neglwt or rcfust* to t«ke in 
sufficient quantity, is common tmf^r. The habit of iiixl'tkiiirf 
water may Ih> oven-^ime by a [ileiniful use of ci^rnvmn mU^ 
which pnxluces thirsL l>ate in pregnancy, when (here is 
Utile spore for a full stomach, the lueids may l>e small, but 
t»f more fretjueut rei»etilion. 



PISJ^ASES OF PREGNANCr 



133 



7^<? »Ht» must l»e kept clfJtn by imrm hatbs (itol l»»l, uot 
(Hilil), takfh iit li'iist llirtH* liiiit'H n wivk. St'u-l»iit!iinj: U i)l»- 
jec'tiuimhle, vet so in t? women vnjuy it \\illi4>iit iujury. WheOi 
lute in gts*t«ti(.»n, the wouiaii l)ef<:»nu-»i (o unwieltly to uufl^r- 
take a liatli, the exU>rutil ;;eiiiUiltt nitty Ih; cleuuHed with t«pid 
water twice daily, nnd tlie •*kiu rub^^ed with a wet towol. 
During later weeks uf prej^ruaufy the nippUt* shouUl lie kept 
8crupuIout*ly cleau, tree from prt-Hsure, mid K>tleiietl hy appli- 
ciLtioitB of UinitiHi vnwliiu' or iMHija-lnitier. 

Sleep iii imjKjrtaut. It* practicahle, a pff^naut woman should 
retire early^ ot-rupy a l>etl l>y hen*elf, and sleep eipht hours or 
more. While roituti alter ijuureguation i» a phvhiolofrieal nl>- 
surdity and ought to be avoided, it will UHualiy ot^'ur in spit* 
of any advit* lo the contrary. Indul^emv at tinu-p eorre- 
Bpoodiug to the meiiHtruni jieriod is liatd© to cause abortion 
in thiise pre^iii*|Kn^e<l lo thi^ event. If al fliinenee he refusedi 
enjoin nuMleratiou, and lirief ini^ead of prolonged sexual 
exeitenient. 

Uuder all cin*unit$tauee& eneouragc the patient to refrain 
from anxiety and fi':ir of lier apjiroarhinp travail. Substitute 
induHtry and wn-ijd cheer for indoleniv and solitary* brooding, 
Bvoidiug alwayci emotional excitement 



DlR£ASGH ov Pre(;naN(:-y. — The diiieseeB incident to preg- 
nancy are nuraeroufi and varie^l. 

I>^t it he reniondiered that most of them are due either, lat, 
t<:» nt/mfHitfnf — i>th*T orj;ans Itein^ disturbed in <Hnise<|uem?e of 
the tremendous I'lianpen poinp ou in the rcpri^MUK'tive system; 
or, lid, to ftrt'HiniTp — the me<:haiueal pressure of the gravid 
ut«5rUH n|Htn neighboring purls. Syni|mlbetic diisturhauees 
preilominate tlurin;.' the earlier mouths, meebauical disturb- 
ances cturin^ the Inter oneit. 

The opposite blood txiuditionB of annnia and plethora ahuj 
play an in»|>ort«nt r^U in determining the charaeter and trejit- 
uient of ihene diw^juitH. 

A)j:nin, penerally s(>onkinp. the iirn'oun ^iftHfTn iV more fua- 
erjdibU In imprt^oitu tUtiiinj prryminctj than at other timet). 

Finally, tumw of tlu* imthoUi^ical ronditintis to lie Htudied 
are inniply exa<rK^ni(i<ins of the physiolo^^inil pheuomena ordi- 
narily numbered with the UBual tngns of pregnancy. 



134 HYGIESP: and PATUOLOOr OF PRKOyAXCr, 



CLASftiKiCATloN OF DlflKASKfl. — No cI«*nficat!on of tht' 
(lirieikiert of pn'^iiancy yet (levwwl is |RirftM!t; all tin' urlntrary. 
For coiiVfiiii'iKf* w»ke we nmy ffroup the several aHwtioug 
to 1>e ooitFiitlcri'il (continin^ the \wt tu thot^ arttuilly due to 
pregnatwy) jw lollows; 



1. I)iseiist« of the DipesHve Organs: 

£1. Sulivarv f<lmi(U. 

2. DiHtJUHrt* of the Uriiiflry Organs : 

a. Kithiey*. 

3. Diflen.'*e8 of the Repnxlutrtive Organs 

«j. Uterus. 

A. Vagina. 
4- Difeaiie!* of ihe Circulatory Organs: 

a. Henri. 

6. Vein«. 
6. Diseases of the Hespiratory Organs, 

6. DifleoMud of the Nervfius Syntern. 

7. Diseupes of the Skin. 



Stomach. 

Inlt^tinea. 



ft. Bladder. 



VuJva. 
MnninifB. 



& Blood chaDgeflL 



Salivation of pRKtixxNCY. — SymptotM, — AconstantdritY- 
bliug of shIivu, day and uight, lint no oHensive hniith, m* in 
mercurial wdivuliun. Orcnn* usually iluring the early months, 
but may eontinuo during (he whole of pregnan<'y. It varies 
greatly in duration iw wfdl lus in dc'gree. Bnrral mucous 
nienihrane may be rt'd and tumid ; the submaxillary and 
parotid glands tcntler and enlarge*!. The water of the saliva 
ia incn^iuseil ; it^ soli<U dimininhiHl. Ptyalin may InMleficient, 
and digestion cousefjucntly impaired. Occasionally ginffhniis 
occura, the gunifl i>eing re<i. swollen, tender, sometimes {deed- 
ing on presf*nre nnti retracted from the teeth, which become 
loose, with difiicMilt and painful mastication. 

Prof/notiiii is* doubtful as 1<J cnrf Ijcfore delivery, tmt no 
serious con;*e<|uences nee<l Ik* apprehendetl further than anxiety 
and annoyHn<*e. 

Caujv. — It is one of the si/mpathetir afrectioufi. The sym- 
pathy Iw^tween the salivary glands and the generative system 
is well known from the phenomena of mum|)8, coition, etc. 

Trrntmeyxt — By gentle saline laxatives, whirh divert the 
exceaaive secretion to the intestinal glands, and by aistriugent 




DENTAL CARIES AND TOOTHACHE. 



135 



tuouth-wa>ihes of tntmin, alum, Hul}»hate of zinc, or poUiwium 
chlorate. Coiintfr-irrilalitm l>y liiuiure <»f itniim' nr small 
blitftent exlerually, uvtr the |mroli<lH. Exlrm-l of U'lUMhuitiu 
(gr. i, three limeu a iluy), or t?<|uivaleut dosses of atropia, uuiy 
lessen the discharge. Pilocarpiue (gr. ^) and Huid extract 
of viburnum have been recomineode<L The tbltowiug gar^jfle 
may t>e usetl two or three times a day : 

B. Sodii boracLs gJycerini, f Jij ; 
Aquffi TOBaSy vel aquiE, f 5vj. M. 

Bromide of i>ota>i^ium has cored 8ome raises ap|virently. 
Iron aud other touics, with geueroun diet, are imj>ortaiit. No 
treatmeut is reliable. 

Dental Caries am> Toothache. — That pre^ruancy actu- 
ally caupeg the teeth to decay if* a widespread lielief amou^ 
physicians as* well as laymen ; hence the proverb, "for tvery 
child a t<M>tb." It hum l)eeii a-scribed to acidity of the onil 
accretion from dyttpe|it*ia. l>ut ((uite a« likely it is due to nial- 
uutrition of the teeth from certjiin ctmstiineiitit of their com- 
piwitioi» havini^ been n[>priiprialcd to nutrition of thi* iMiibryo. 

Trcaimenf. — In rc<*ouiniending o|)erative pnK^eilures u|toii 
carious leeth duriii^r prejrnancy, thp det'ree of " ner\'ouiincs«'* 
or emotional susceptibilitv of the fiatient, and the severity of 
the re«|uired operation, should enable the ph)*sicinn to jiidjre 
whether the mental ph*K*k or physical sutl'erinjr to be incurre*! 
would l>e likely to bring on abortion. Conclusion wcord- 
injrly. 

in ca*<e no o|>erative prm'e<lure i« HAfreed to, a dc«*e of 
Dioqihia may l>e n4iministere<l hyf)odermirnlly for immrAiaU 
relief of tlie [Niiii, to be followed by auodyuea^. and quinine in 
JuU do9e$, thuH: 

B. Quinia* eulph. fsr. xxx : 

Morph. sulph. trr. «8 ; 
Extr. litdlatlonuie. ^r, j(»; 
Acid. ?ulph. aromnt. <|. s. ft. pil. TJ. 
-Take one everv f»>ur bouiK 



Sig. 

Other remeilies are : FUi ext ^elsemium, gtt. iij-v, 
times a day, tintil slight ptosis oceurs. Croton-chloral. gr. 
every hour, until not mure than Hftt*en grains are Ukken. 



threo 
ij-v, 



^ 



13G UYGIKNK AND J'ATIIOLOGY OF PREaXANCr, 

External ly, warm npplinitioiitt tinil anudyne linimenta (of 
runipliur. utxMiitc, iHihlaiiinii, t-lilorDlanii, eUx) may aflord 
relief, NeiiiHl;:irt ni' the face itic tfouionreuar) ret|uire» tlte 
huUK' reiiidlii^ Fiie^^clie, lieiului-he, intcrouHtul iieurul^io, 
and other forms of the same disease, wlicii euused l>y atifmiit, 
require //•*>«, lo which arsenic niiiy be jtrotitahly ad<le<i, as in 
the foUowiu^ funiiulu from Lu»k : 

R, TulviH ferri. gr. ij ; 
An«nio, gr. ^. 

he taken in |)ill, Ihree times a day, aud continued several 
kkit ; t.>r, 

Ferri et quinie citras, gr. v ; 

Aqme, ^, 

throe times daily at meal hours. 

To arreftrt caries of the teeth during ]irepnane)', Dr. Hirst 
reiTommciuls syrup of the lacto-pha*-'phate of linie, one dram 
three times u day. 

DeRANOEMKNTP ok TIIK S^rOMAfH ; ExCESftlVK VOMIT- 

lN(t. — S}/mj/(oiM. — Exa;5;rerKtion of ordinary '*moruiii>.' gick- 
ueea," Vomiting inereas^'d in severity, duration, and fre- 
ipieucy. May eome on at all tiuu-K day ami night. Ejected 
matters contain, successively, r(tod, dear mucus, and re^urjri- 
tate<l hile. May \te severe (lain in the t^tumach from eontinueil 
rvtehiug ; apt to continue ww^kn, or even month?, in pjnte of 
treatment; then follow: ro»>f^V»//i«/K// wvHi;y/o?/M, fever, or suIh 
nonnal temperature, eniaeiation. restletwuess. exiiaustion, and, 
later, fetid breath; dry, brown tonpue ; feeble and fretjuenl 
pulmj; uipht-Hweata and jum)nuda. Still later, iu the worst 
ciu^.-!*, vomiting stop!" (from exhaustion of reflex jiower of the 
Hpinal coni), and uorvouH symptoms appear, vi/.., delirium, 
Htu])«>r, coma, aud rarely, irtif rarely, death. Vomiting of 
blood, ev^en severe hemorrhage from the stomach, may occur 
in eases of ga.stric id*'er or cancer. 

/Vrt#7/mMV — Cases apparently hoptdeRS 8ometimffl "turn B 
corner." jis it were, and eud in rtM-overy when it is least ex- 
pected. The symplomi* nmy stop fron» surlden mental emotion, 
or the occurrence of }'|M>ntane^>us abortion ; or. aptiii. a new 
mediciue, or eome i^peeial article of fo<xl or drink, may sue- 



DERAS15EMKSTS OF THE STOMACH. 



137 



?r many others have faiIe<L The pravit.v of tht* prog- 
noHis increjL'U's in pro|H>rii()n tu rouMitHfiniml syniptotiis ami 
failure of jj;eiienil nutrition. It is wor^f In th<JH; ui^w* inmipli- 
caUyl with Koitie gastric or iut4»tiual tlisfmst) previou:! to preg- 
uaucy. 

Cames, — Most ca^es of moderate severity may he attrihuted 
tu reBex nervous derangement^ just a^ vomiting atletnljii diin- 
eases of the uterus. Stretching of tlie uterine muK-uhir iihrea 
by tiie g^rowintf ovum ; Hrxions and ver-siitny of the wotid) ; 
iuAammatiou of the uterus, either of itii Inxly or ueek ; ohJ 
peritouenl adhesions himling down the ui**rus ; or j*everal of 
these conjointiy, mny fonatitute eti<)h)^eal factors. Previously 
existing jjnsirif catarrh, ulcer or cancer, and old iutestiual 
lesions may explain some of the grave cases. 

Treatment — The remedies are ** legion." When some fail 
others must be tried. What will cure oue case may he futile 
in auother. 

Did, — Total abntinenee from foo<l or drink mny l>e tried for 
a whole day. or even two or more ctunploto ihiys — a mode of 
treatment easy of njiplieatiou tnrfy, not so later, when the 
patient is exiiausttMl. 

Liquid ilifi, in siiiuH tjujiiititifs fn;<piriitlv rc|)eated, in pre- 
ference to solids, the r)rcU*r of selection t^ iolltjws : 

Milk ; milk with stKhi-water ; kounnaR. 

Iced milk. 

Meat soups : either 

Beef, A 

Cldeken. !- carefully freed from grease. 

Mutton. ) 
WellHVK)ke<l farinaceous liquids: 

Harley-watiT. 

ArrownK>t. 

Rice-water. 

(Virn-starch. etc, 

8houhI these fail, nnd the [uiticnt avow a rlrtttrr for bacon 
and cabbage, jK>rk an<l beans, onions, green applce, horse- 
radish, muHtard, or any other apfMirmihf un.**nitalde article, 
give it to her as an ex|)eriment. and put thn slo{»s aside. 

Felting ordinary •'pop-corn*' will aometiinea stop it; so will 
chewing spruce gum. 



1;38 UYOIESE AND PATHOLOGY OF rRKGNASCV. 



Ice-creani, rnicktMl ice, ice-water, aixl water-icw* nmy do 

gmxl Hervifo, 

Wakti the patieut at iuiilitit;ht, or in the early nioroiug 
hours, and give her (while reeuinivent) t<»a.st ami enti'ee, or au 
egg. then quickly put out the lights and leave her alone to 
sl(«p again. FotHl thus given may he ret4iined when it would 
l>e rejtftetl at othtr times, 

.SituixmI iK'ef, featt and rau\ S])reml on very thin bread, is 
worthy of trial. 

Ill awe:* where no food can be retained and the general 
nutrition U-giiiFt to fitil, the |>atieitt may Ih* HUHtainetl. for weeks 
together, by rectal nliuienlalton alone. Pe|>tonize<l lieef teaaml 
other animal hn^ths, |K*|»loni/A'(i milk, white of eggs slirre*! 
in water, etc. in i{uautitieti of four or live ouncres, three times 
a day, may \yc injected. Tiiirlure of f»piuni. or iiotaasic bnv 
niide, or brau<ly, nmy l>e added to the eueinata aa circum- 
Btaneeg may ruquire. DiarrlKca and rertal intolerance, by 
preventing retenlioii of tbe iujectiomj, may exclude the use of' 
this treatment. 

To relieve ilistn^twing thirst, a [lirit of nornml salt solution 
may Im* injected high up into the lK>wel twice daily, the rectum 
having Iteen previously rleai»sed by irrigation. 

Mnlinitai RnnrrlieK — Of the varioiw me<licines uwd. ititiim- 
IKWsilile to say which will suit any one ca«e. For convetdenoe 
of rectdleclion they may be arranged into groii|*, as follows: 

1. Purgativnt. — A brisk cathartic pill, or la.xative enemata, 
until IiovycIh are freely oj>en (e*(|>e<-ially if there have been pre- 
vious foii.sti]>aiion ), will "work wonderM" in relieving emevift. 

2. Heflrx SedaiirfA and Anoiit^tirA. 

B. PoUuv. bn>nud. gr. x-xx, in some aromatic water three 

times a day. 
B. Chloral hydrat. gr. v (a small dose), g^iven in H(duti4m, 

every two hours. 
B. Pulv. opii, gr. j, given in a single pill with as little fluid 

&n possible. Not tcj be rejieated. 

Should the stonm<^h rejo<;t all these, 

B. Potass, bromid. ^ ; or 
B. Chloral hydrat. gr. xx ; or 
B. Tinct opii, f^ss, 
may be administered in a nutritive vehicle, per annnu 



DERASQhWESl'S OF THE STOMACH. 



139 



Mor|»hiii — preferably the Innu'toiiato — ^\\vn either hy|Kj- 
(lennii^lly or emlorniicnlly (H|»niikle<l on h Mistered surface J. 

Anodyne jilaften* and liaiiiieiiU*. or ether spray, applied 
over the epi^iwtriuni ; also eoiniler-irritunUi, e. g., imitilard, 
eanthuridal eoilodiou, or blisters of Spuuinh fly. 

H. AU*i(it^j<. — Esfiet-ially suite*! to i-nse^ of aeid stomach, 
hearti)iirij, etc. (iive at], calcis sss with .^ss of milk, and 
re|>eat every fiiUfn minutes; or Vichy water; or Mmj.M;e.sia 
with milk ; or the aromatic ,spirit<( of ammonia {<N se xx 
drops) iu ^ of ».»nie aromatic water; or bicarbonate of Hoda. 

4. AeuL/. — Lemou-jnice, oranjje-juicts or the acid. Hulphuric. 
aromatic, (dose x-xx drops) in .y of water. Citric acid 
(9ifrnp. actfii citrici, V. S. P., fX»*)- Carbonic aciil (gne), a» 
in soda water, or the eHen'e«cinK draufrht of the C S. I*., 
etc. One or two dru|w of the diltiir hydrocyanic acid may 
he ad<led ti> the latter. 

5. Anwmtir BiUer Tonics, — ^Tinct cardamom, co., or tiiict, 
pentiun. CO., or tiuct. cinchon. co., or tincl, rhei dole. (do.*;e 
of each about 5jj, or the infusion of calnmba with aromatic 
Kulphtiric acid. 

(i. lutoriratinrj DHukH. — Cbampafrne ad libitum. French 
brandy, slierry, whiskey, fcir/*chiruiii<fr. Kilher may he lrie<l 
in snflicient fjunntities to province siiirhl intoxication. To lie 
retiorled to only allcr a trial (if les* objectionable nielhods of 
treatment. 

7. Vnrhmified Rnnrdiea. — Given empirically: 

liismuth subnitrate, do*>e pr. x-xx, before each meal. 

Saliciue, gr. v-x. three times a day. 

Fota-ss. iodid. ^r. v. three timew a <hiy. 

Oxalate of cerium, jrr. v. to x, before meals. 

Vinuni iix-cac. jrtt. j, every hour. 

Creosote, jrtt, ij, in a<^. calcis ^ss- 

Phnephate of lime, pr. xv-xx. in water. thre<f limes a 

day. 
Tinct. iodinii rowjjt). git x-xv, dihiteil, three time« a day. 
Fowler's solution of arsenic, ptt. j, tliree times* a day. 
Tinct. aconit. rad, j^t. ij-iv, three times a rlay. 
Tinct. nucis vom. gtt. x, three or four times daily. 
Muriate of cocaine — three per cent ifolution — ilose gtt 
x-xx. 
'roxylic spirit, gtt. x, largely diluted, t. i. d. 



140 BYGIESE Ayp PATHOLOGY OF PRBaSASCY. 



Ktill uther ivmeditv mnr be ne<'eBar>'. h« tlie nvturation of 
ftdiflpbu^l or f1t'Xt*il uUtuh nnd iti« i^up|M>r1 l>y « |tet«t;irv; iu 
ciMM i of hiltaiiuHl Lvrvix uteri (or eVfi) when no Hurh iuHuiu- 
mation exuU) \io\xt n ten per cent solution {>i nr^rentio nitrate 
throu};h a ^lans Apeculunj into the vajfiua until the vaginal 
|xirtioii of (he t«rvix in (^nip)etely ituUiiierf^i ; let it remniu 
Uti or Htl<^u minutt"!*, then <iet*ant it : to U* rcpeateil two or 
thret* tiuiHH, at inlerval^^ of a few days. Helief id Kmietiuies 
obtained liy njiplyinK anodyuett to the eer\'i\ ami vault of the 
vagina : a tifieeti jut itnit, wdution of rnurinte of eofaiue, or 
the rxlraet of Iwlhidonna, or Baltley'tf »e<iative, may \k' thuH 
applie^l with a |ir4)be and <N)ttou w(h>I. or raniel-huir brush. 
Dilatation of the u8 aud cervix uteri with the titiger will 8onie- 
tinim aflfifd immediate relief, hut cure niui^t !>« taken not to 
pnnlure uliortion in this way unintentionally. 

A \i\\\i iif rnukeii it-e n|>plie<l to the cervical or di>r8al Ter- 
tebnc for half an hour, iwt> or three times a day, will eouie- 
tiniw 8to|> the vomiting. Pencilling the fauces with a tea per 
ocnL mdution of muriate of cocaine \\i\& l>een lately suggested. 

The (at Itenf, un]>hys*i(do^ical^ practice of coition during 
prc}<nancy is prohably one of the cauM^ of thin vondting, and 
ehould l>e interdicted. 

Shouhl all niean.s of relief fail and constitutional gymptonui 
of a ^rave elmnicter ariiw, the hud rei*ort may l>e adopted, 
vir.., the intbj<tion of alM>rlion or premature lalM>r ; but the 
canes rei|uirin;r it are irri/ rai'4\ and it is not to l>e emphiyeti 
with(»ut u couHuttaliuu of two ur uinre pliVhiciaiKS. 

The bcHt mcau?* wi' inducing MlH)rtion iu the*»e cji«eH is by 
dilating tlie cervix uteri ; hut um miMlenite dilatation with the 
Hn^^or, Its just stated, will olleu Htop ihe vomiting, this should 
firai 1h» doiitf. wlu-n, if the vomiting cejwc*. further dihitalion to 
produce aUirlion will be unne^x-jwary. This mcHJeof amv^tiu^ 
vomiting was di»covereil ac<ridentally by Dr. t'openian. The 
method Iware bin name. 



DKRAX<iKMKNT <»F TMi: iNTKfiTiVE. — rotmtipntion is very 
cuininon. \j^^ often diarrhu'u occurs, ConjdifHiti\m is n sym- 
piithc) ic nire<'tioM during; the early monllin, and due to pretiHure 
tif the eidarf.'1'd womb duriiij^^ the later ones. 

Trtahnt'nt — ^Diirinjr (lie early month;* nu'Ot wiline laxatives. 
taken larjrelv dilutfil before lireaktiwt. After their action 




DlARUltiEA. 



141 



instruct the natieut to vinit the ckitfet daily at a regular hour, 
untl tMie j^oiitle tmiAmtj^- of tin- uImIohumi wliilc there. Oatmeal 
|K>rricige, and brown breiiil, l)raii hreud. or <x>rnniwil breatL 
(*ool water to Iw ilruuk every moniiup before breakfoat, aud 
iiT^nin ihe Inst thine ai iiij^ht (Jro(vr*R fipB, liatws prunes, or 
tanuirintls at ni^ht before drinking tlie water. Forbid tea. 

Dnrinj: the hiter months, when nuuves of acybala are liable 
to accumulate^ cantor oil with tinct. o]iii nmy [>e ^iven. and 
injections (daily if re*juired, at a rejjuh»r hour) of soap and 
water ; or hot wuttfr and iriycerin, e<juul parls ; or rectiil suj)- 
poeitories of pure jjlycf riu. 

Shouiii s1ron(,'^er nunlieines he nece^jsary, either early or Inte, 
manna nmy be given, or extract of eohK-ynth with extract of 
lielladonna, or an oct^isional blue pill with Hoapand n.>4af<etida ; 
or a tea>«l>oouful of coin[H)un>l liquorice |K)w<ler at nijrbt ; or 
B. Eit c'olocynih. eo. gr. ij, puiv. rhei, (rr. j, ext. belladounai, 
^r. I, est. hyoKcyumi, ^r. as, in piil, at bedtime; or H. Aloiu, 
gr. I, Ktrychnio, gr. ^, i]ieciu\ gr. ^ ext. belladonnic, gr. i, ia 
pill, at night. 

Impacted fe<-al mai^v> s^uuetimeH require removal by tne- 
chanicnl mean^ and iwdvent enemata. 

For chronic oonntipation dirwl niHSBupe in the closet, thu« : 
When t»eated, let the imtient jihu-e her arms **akinilK)/* the 
thumbs directed backward and plnnired into the spnee on each 
«<Ie of the lumlter spine below the ribi*, while the hamU are 
spread out l)elow the rila* laterally, and h<j movcnj aliout m a 
<'in'le round the body, the emU of the thuude aud iiugers 
makinj: intermittent pressure. 



DiARRH<EA. — If it have been preeetled by ormrtipation, 
and the evacuations contain but little fwal nintter, and consist 
rhiclly of mucus, ^ive a jrentle laxative of castor oil and 
lauilanum. or a d<t8e of solution of citrate of magnesia lo 
cleanse the bowel. 

After Heinj: Hure that no accumulation in the Ixjwel re- 
tnains. and in cai*ei» where none oripnully exinted, ^ve ve^e- 
lable iwtrinL'etitJ* with opiates, rj-. tjr., the tinctures of kiun, 
pnt«*hu» or kmincria (ilowe of either 3 j j, ^^ith tinct, opii, ptl. 
X. in J.i-fi iif ndril. cretie. thn*e tinu* a day. **r pills contain- 
ing acetate ttf lead, opium, and i|K'cac nmy ^^e preseribed, or 
syrup of rhul>arb with bicarlHinate of ztoda. 



142 IIYGIESR ASD PATHOLOGY OF PREGNASCW 

In addition enjoin miiscwlnr rest and the recumbent post^ 
ure ; mustard, followed Itv vviirni ratiipla.snis to the nhdoiiien, 
and milk diet with well-oouked rife-Huur, urrow-rmtt, or coni- 
Hlarch, eU\ 

The ot'currence of diarrhflea during prejfiiuucy inuhl nut be 
neplt-cteii. l'ule«» ol»eeke<l, it may lend to al^ortion or pre- 
mature delivery. It should \te treated with great eare, es|)e- 
ciaJly 11* aetx)mpauied with teuttimub or otber si^nis of euler- 
itiB. 



DiSEAPKH OK THE KinVKY AND BLAimER. — AturMIN- 
URIA. — The frequency with which albumen oeeurs iu the urine 
of pregnant women ha« been variously esfti mated at from two 
to tMenly i>er cent 

It may exi>i when slight iu degree, and especially if only 
duriitg the later inoiitli?*, without any marked ill health, or 
witluiut Iving psuHpected uuK'j^h the urine be tested; l)ut in 
other caf*i^«, where the (pnintity of albumen is great and hegins 
ti» apjK-ur early iu the pregnancy, the prognwia may be of the 
gravest character. 

Etiofntfi/ ami Pathology. — Nothing is more unsettleil than 
the caUBeB and |»alhology of the renal trouble** of pregnnnry. 

Albuminuria in only a gt/mptow^ which may or may not he 
attendeil with structural legion of the kitlney. All known 
Ics^iotiH of the kidney — every variety of nephritis — may iH-cur 
in pregnant women a/t in otht^r pt'rmitit. In Home women renal 
diwawe \h present when gey-tation l)egiii8. While *<tnie cin^en 
are thus accounted for. there are othern iu which renal discaiM! 
ordy begins during pregnancy and dif^ippear^ after delivery. 
It i.H tbffie lajsl that are difficult to explain. That the morbid 
comlitiouH ohst*rve<l are in some way produced by pregiuuK'y 
cannot l>e doubted, an<l that previously existing renal disease 
is maiie worse by geMtation is equally true. Theoretical ex- 
planations that explain t«ome case^ fail to explain others. The 
etiological factors probably vary in kind and nandier in dif- 
fereut cjit»ej». Some of thejie factors (the relative [>otency and 
frequency of which it is dirticnlt to defiuej are as follows : 

1. (Htt*truelion to the ureters owing to their being "stretched, 
ilexe<l, distorted, or conipres-ted " by the gnivid nterus. 

2. Sudden hy|»crenua of the kidneyN pr*MlutXMl by cold and 
cuiifte(|ueuL sujipris&ion of |K^rspiration 



DISEASES OF THE KWSEY ASD BLADDER. 143 



3. Increaae<l functional activity of the kitJuevs, required 
durio/:^ prej^uuncv to oxcrete waste product of the fwtus. 

4. Iiu'reiLsod hltntd ]tr(';**»iire ill vesHoljt of kidney from jren- 
eral arterial t^-nnion lhn>ir'^hi>iit the Inxly. i>wiii^ to cardiac 
hy|>ertroithy (pbyHiolotriuul by{>ertro|ihy of left veutricle; in- 
riilKiit to prejrnancy. 

o. MtHihanical pre&jure of the pravid uterus ii(to[i IiUkmI- 
vtHsoI* — either vcitts, arterittt, or Iwtli — so as to disturb the 
renal circulntion. 

6. General increase in intra-ahdorninnl pressure owing to 
tension pro<luced by expamliii^ pn-jL^naut uterus, an<i pro- 
ducing venous atainiM iu the kidiit*ys. 

7. Reflex vaj?omotor spariin uf ihe renal arteries ("and conse- 
quent renal aiiienua) ori^rinatiiig |)eripherully fnmi the uterus. 

K The alleged bydritmic condition of tbe bbW incident to 
pregnaucy. 

9, Anomalous iliHtribntion of lan;e blood vei*»elj* in the 
abdominal cavity, such ectopic bKM>dve»H'lH In-ing m<^rt.^ liable 
to inechaniciil prea^ure by gravid uterus tbaa ves^ts normally 
distributed. 

10, Al»8orption into the hlootJ of toxins from the inteHtine, 
owing to rleficient action of the liver failing to eliminate these 
toxic materials during [ireirnancy. 

None of tbtwe views have been ctiuchwively proved; most 
probably a plurality of etiological factors act conjointly. 

The lesionrt of the kiibiey vary, depending largely upon 
the existence or non-existence of structural changes prior to 
geMtatiun. The evideuL'es of nephritis, a<'ute or chronic, inter- 
slitial or parenchymatous, may or may not be present 

The coiuliTinn known a« ** /Ar Icidnetj of prttftinnrtf*' consiRts 
of anemia (»f the organ with fatty degeneration of its epithe- 
lial cells ; hot ii'itfuiHt ne|ihritis. It is of frequent occurrence, 
hut of less inijHirt than nephritic cjises ; its symptoms are less 
pronounced, apjwar later, and dlsi\p|)ear more promptly after 
delivery than in c:ist* where there is intlHunnation. The treats 
lueut of Imth conditions is practically alike. 

iSt^mpfoniA ami I>i<ifftun*iii. — The urine of every pregnant 
woman shotdd Ih^ examineil ni t^hort intervals. (*s(ttH;ially late 
in pnv^anry, both ehemicnlly and ndcniw^tpically, for cvi- 
denn*s of kidney disenst*. Albumin is detect***! by fwifimj the 
urine, which coagulates the albumin, as does alsti nilric acid ; 



J 




144 IiyGtKSK AyV iWTliOLOUY OF PREOSAyCl 



but hcjit wiil frtve a prcfipitate resenihlinp that of albumin if 
|ilHii»plijile« be i»ro(»eut ; tbiii, bowevor. m^ immediately letiis- 
Holved by nitric aci<l. Tlie amoiint of iilbiiminouft prwipitate 
nitty vnry from a barely iwR-eptihle tipalew-ence t(» up)mreut 
eoniplelt: militlifiraiiun. Albumin is mtl always continuously 
pretM'ui : it may he ahseut onti lUiv and appear the next, or 
tice rci'm — hence tlie examination should be re|)eate<L 

The qttatititif of urint* imuwhI in twftuty-four hours should be 
colleete<i and mea«ure<l, and the total amount of vrm it pon- 
tflinft be appn>ximatcly n>«Trtaini.Ni. ThiH can be conveniently 
done by \mu\L the ureometer of Pn)f. Dorenins with the sodie 
hy|K>bron»ite »i>lniion, which gives the grains of urea in ciicb 
ounce of urine. The totnl quantity of urea excreted diiily 
should not l>e less than 400 or .')(»0 grains. 

ExaniincMl nii4n)«'opically the urine exhibits renal epithe- 
lium cells, tul)e-cjiM> — either hyaline, epithelial, or fatty — and 
perha|>i ral bliXHl-curpu.scle.s the presence, number, or al)sence 
of these elemenlH varying with the kind and blage of kidney 
leiiion. CiLsts nuiy be prtssenl \iitliuiit albumin, and Wcr itrwi. 

Should ulhuniin ap|>ear early in prcgrtancy, an*! in suffi<*ient 
rjuanlily to i-onstitute a wriouj* caj*o. the following smptoms 
may bo sncceHHively nnticipnted : 

Anawirrtt, begirniitig usually in the lower litiib-s but if the 
kidneys be sorionslv iniplicute^l dro|*Hi<*nl puftincsp t»f the face 
and hamis n\«y oifiir /?rxf ; it may extend over the entire bmly 
and alritt tu tlic j*eronH t-avities. 

Thf urinr beootnes higb-rolort'd (dark, or smoky-brown, from 
admixture with bliHHi l, diniinifhe*! in quantHtj, or it may he 
pnrtiallv or suddenly and completely avpprejimeti. What little 
is ohtaincil i.-* com|M»peil largely of albumin and show** an abun- 
dan<e of tulKM-jiKls. blo<Ml-corpu>trles, etc., under the microsi'Ope. 

yrnytus Sfnnptftmji. — The kidneys failing in their function, 
urea begins to accumulate in the bhmd and |>oison the nerve 
centres: hence occur headache, vertigo, miusca. vumiting. and 
epigastric pain ; derangement of Kpecial senses — imjiaired 
flight, hearing, etc. ; the breath and |ierRpirnii(m may have flji 
ammoniacal. urinous (Mlor. I'tdess relieve*!, thw**^ symptoms 
ttrminale in 

fnmifr mmvitltrioutt (so-called " e<*lanipsia,'* s|Hlsnis); fol- 
lowe<! by stU|X)r. going on lo c<tmplete coma, i^ierhnps death* 
(For plienunieua uf eclaiufjeia, see Chapter XXXIll.) 



DISEASES OF THE KWyEY AND BLAVDEH. 145 



Premature delivery may occur, or if the case reach lull term 
conviilHions may l»e !(M»ke<l for diirin«j hihor. 

After (ielivery the coiiviilsioiis may ciuise ami the piitirnt 
recover ; or, after |Mirtial recovery, the woman may die later 
from chnniic Bri;_'hl's liineiLs*' ; or reiimiu more or le«j disahled 
from [wiralvMr* ur mental derangement. 

ProijnotnJi, — Comlitions renderiiifr labor ditticidt ; the alum- 
ilaut occiirrenc'e nf tuhe-ca?iU« and exteiutive dro|t*y, especially 
i)f t!ie fa<*c and liands t'urfij in urejrnaiicy ; together with indi- 
catioiih of uncinia — all aufnir unfavornhly. 

The fate iippeiirunce of HymptoniH, dropBy confined to the 
lower extremitiefi, unemic symptoms not imfteudiiip. and the 
prohnhilities of an ea^y labor, aii^nr les« danper, ej*pei*iully if 
the albumin be smiLll in (jimntily and lulic-casts are wautinp, 
or few in huuiKt, and tlie uriiu' is not *u|ipreK«e<I. 

Treatment — Piirjfatives to produce wnterv tttn«ils and thus 
promote excretion from the iHjwelH to relieve ihe disabled kid- 
neya. (Jive pulv. jalap, co. ,".ss ; or calomel and jalap, of euch 
ten grains; and k(*ep up a free action of the bowels wilh a 
daily pill ci>nlaining extract of aloes and extract of colocynth, 
of C4U'h three-f]uarters of a ^rain, taken in the morniiiu. In 
bad <r<we(< with symptomn of impending; unemia, elaterium 
jnay l>e piven, hot with care to avoid exhaiuttion and pro- 
duction of prematurf luhor hy its dnistic eHeels. 



B. Triturat elaterini, gr. 

Extr. hyowyam. ^r. j. 

Ol. cnryophylli, jrt j. 
S'uj. — For one dti.se. 



M. 



I 



Of e<pml importance with purgation is promotion of the 
Becretion of the i*kifu preferably by the hot water or vajwr 
bath. Submerge the jtatient. all but the head, in huth-tub 
of hot-water — 1(>2° F. — roventl wilh a blanket I-et her so 
n'nniiu thirty minutes, the tem|)enitiire of the water beinj^ 
jrrailually increased la IIO*^ F. On removal from the bath 
wrap the palient in a hoi sheet, place her in b(*<l lietween thick 
wcMilen blankets, and covered up all but the face. During? 
the lialb eold wet clothH may In* apjilied to the hemi to relieve 
headache, etc. ; water drank frwdy to promote diapb(»re»i«, 
and n jrbiH* of wine jriver» if faintnes.s mvur. (tunrd afrninst 
«X|Ki8ure while cooling ofi*, rii^inp from UmI. and dressing. 

10 



i 



Ut> IIYGIESE ASD PATHOLOGY OF PHKGSAUCY, 



Bath may l>e repeated on(^ or twife daily, ll has one draw- 
imrk, vi/. : the liaMlity to liriii;; on iitt^rino iMmtraLlion and 
lulior. (.'hlonil aui) the hroinido^ may [irevwit this. 

Wht'ii the walt'i'-lmth is imX availahle iis<', ihi* liot^tih* fnith^ 
lhu8: plure a t4[)irit hiinii uu the Hoor near the l>t^d ; over it 
arrange a hir;je tin fiiimel, tho luni; heiit i>eak of which, phu'ed 
benealli the l>e4h-h)thes, <x:>iiduet:^ the hot air to the .spncf ocrii- 
pieil hy the putietiL It rimy he i.'otiliiiiie«J hall* an luKir, and 
repoateil daily. 

The ii>t? of jaUtraiidi and ))ihK>arpiiie as diaphoretics is tiot 
ndvisahh', tVoiii their lial>ility Ut depre.sw the hearths action, 
produi-e pidmonary o-MleriKi, and hriiiir on laU*r. 

Lestten roujjestion of the kiilneVM and prnnioir tlieirsooretion 
by cxteiii^ive dry euppiu^, with liiuihler ^du*.rti, or large cupB, 
over the loina, folh>we<l hy the applieation of BinapisiiMS to the 
t^ame part, and then hot |K)uliieej4 eoiistuutly applied. 

The woman may l»e phieeil in the knee^*ht»it jwitfture or iu 
the Sims |Miisit,ion. to rethice the prt^jwure of the fjravid uU-riis 
and throw it^ wei^^lit forwani towanl the ahdoudnal wall and 
away from the pclvie hritn. 

Diuretics : K>ve Virhy. I*oJaiid, nr Huflido lithiu water 
freely,' nr the eitrate of lithia in r>-ijraiii doses with infuHinn 
of di^ritalis, or, more «>nvei*ieritly, the lithia salt inny \w diw- 
solvetl ill water, eaeli dwe eonlainitiy one or tw<» drt^K of fin id 
fstntf'i of dijritalirt— more reliable than the thirttirt: 

The diH should Iw ohieHy, and in bad caiw* exelu»ively, 
mUk. Milk is it.^elf a d'ntnili- ; it ii* eiwily H»»imilnte<l and 
leavert little unalw))rl»e<l drbrU in the inti-s'iine. Sdid f<Mnl — 
ed|>eeially mi-at — to U* forbidden. 

Kw<*mly the .snbenljinwuis infusion of common salt stjlutioo 
— the 8o-ealIwi "normal salt dilution"' — in quantitiow of a 
pint or two. at onee, into the eonneetive tissue of the nates or 
abdominal widl, biu Imm^u 8ueetwfully ummI 09 a diuretic It 
'i& harmless and e;wy of applieatinn. 

Olhserve that, httwever the ineanj* may differ, the object of 

treatment is always tin* «ime, viz, : irnturr flit- fmtrtinn of the 

kidnrifH, or aid them by inerea-sed elimination through the 

ItoxctU and tfk'tu. 

* Tlitr >iilts iif ^*'*/ii*A. rcR<itiimnni1i*d in rnrmi-rcfMllnnB of iht** work, »re now 

■ l*n*|>iiriMl hy |iiittHi){ |ii<> tirfiiiift <iii<|iri>\inititrly unt; tk-ii»|MKinriil) nfooinrnon 
vnlt ill n t|iinrt «»r wiihT iiihI iHiinri;; Tir livr- nilitutrn : inert' cxiutly, :i Hntiii» of 
Mil louiip rliiMtiunLV of MKUT, wItlL'li iimkt.'S u fcix-Ceiitlis of 1 pur cent snIuUou. 



DIABETES, 



147 



The treatment miiFt ho mndiHKl nrrorriinp; as the patient is 
ana'niic or j^lfthori*'. If uiui'mic, pvf iruu — the tinct. fer. 
<rhU>. with tr. dij^itiilit! ; or the \\t\. forri et umriionii lu'^tatis 
(IWhnmV mixture), .^hs, to each done of which one or two 
«lro[aJ oi' Jfttid extrai'i uf dijritali!* nmy he athlcd. If plelhitric, 
wet ruppirig over kidiu-ys 

Uu(ier the suptK>8i(ion that rclaiiUMl urea breaks up into 
animouiuni uarhuiintt;, iK'u/oic acid Uaa been given with a view 
to prtHJuc^e tm iuiUK-tioutf amtikouiuin bt!ii»Kite. It i.-^ uf doubt- 
ful eHicurv. Doi*, iive to ten grains, three {»r four limes a 
day, in ><olution. 

Shoidd tlie symptoms grow worse in spite of troutiiienl, aud 
iuvolvement of the nervous (^utred be inilieat-ed by hetidaehtN 
W)nmolen('e, vomiting, dizziue^ derangementrt of the siKviai 
aennes. ele., or s*houUl there be evideuee of retinitis, premature 
delivery shouhl Ih? iiidutxil without dehiy. The oiTUrrenc* of 
deei(h**i renal insuHieietuy during tiie furUt'r montim of preg- 
nauey if ntit relieved by treatment wouhi iudientethe propriety 
of inducing lal>or before the ooeurrenee of serious nervous 
sym[>toius. Authoritiet* differ ; but it is better to be too soon 
than too late. 



DiAnKTEs. fMKi.LiTrRiA. Glyco8i:ria. ) — Sugar nuiy 
be found in the urine of pregnant women without any symp- 
toms of ill health, and disiip|M*ar after delivery, or after hwia- 
tiou. This s<walle<l *' physiologie^d gly<'4»suria" is of fretpient 
wvurreneet. Again, women who are alrejuly the 8ubj(H*ti4 of 
dialieleH may b<*c(inie pregnatit^ ami the pregnaney go on to 
term wiihont any ne<!«sary apparent interference. 

But diabelen ("inuplieating pregnaney may lie serious, or 
even fatal to l»oth mother and ehihl. These cnwe are very 
rare, e^^nH'ially ?o iu primipane. The ehild Himetimes ditfl 
liefore birlh (during the latter months of pregnan<y ), or !HK»n 
afterwanl. The materrud deaths thus far noted have occurred 
after iKIivery or pri'mature lalKir. 

IHaffitfrnx. — Detect sugar by chemical t<*sLs (Trotnmer's, 
Febling's. Mix>r€!*s, etc.). The womb may be over-large fnun 
ilro|isy of the amnion, or from the child iM'ing enormous in 
size, owing ti) dro})8i('al intiltnitiou. Liability to alxirtiou or 
premature delivery. Pruritus of the vulva is apt to o<x*ur. 

Treatment — The dietetic and meilicinal means employed for 




148 IJYGIESE ANT) PATHOLOGY OF PliEGSANCY. 

diabetes without prefftiancy. Should lht»o fail, llie (jueHtion 
of inducing prematum lalior muBt be coiitddcred as a last 

[LADDKR. — Irritability of this organ is imiioated by fro- 
quent di^irc to mifhirute. It cxvtirs as a »»ynipnllifiio aHeo- 
lii)ji during tht* atHi/ lutmlhK ruusiii^ dit^trwf* and hunietiuicii 
disturhiti^iT ^■*^* ^t nijjrht. May alsii i>f jmMhiced by pniIn|ttEe 
of liif uterus duriu;; l\w lirsl llirot' luoiiths, relief H|Mmtan('- 
oiijily ticcurrin;? tn^ the wtuiih riiH* dnno(j; tlie fourth month. 
The worst (.'iiscs, ar(M>mjianied Hiniotinici? by Horious cyHtitis, 
arc (.'onunonly ilue to retroverwifni of the uteruH. In any nuHj 
of irritJible l)ladder it i^ inij>i»rlant to know whether the tronlile 
i»e purely nervous or, on tht* eotitrar)*, tbie to cyjititis. The 
urine tells: in purely funrtiunal nif-v^ it is clear; in rvstitia, 
rloudwl witli nmeut* or pus, whirli may Ive deterKMJ with tho 
niicro!<<'0|K? or *ibK'rved in vi?iibh' striiip* or nm.sK*s when the 
urine, utter settling:, is poured fruni one ve>sel to another, 
Tlie |Mft*^ibility of jrouorrhtea should be reniendiered. In eys- 
liti« the bladder is .Hninitive to nbdorniiinl preK«ure. 

Ijftle in pre^rnaney irritable liladder iR-eure from pressure 
of enlarged wond^ es^peeially when the child','* bead \a large 
from hvdroeephidus. ('ross-prewiitationts sftnieliines <lraj5 the 
bladtler out of plaee and pruiluee fuiielioiud irriuiliility of the 
or^aii, to be relieved by idxloniiiuil |)Mlpatiun restoring the 
ehiid l4> itH normal positiou. 

Ttrntmcnt. — In nervous or fuuctioiitd eai«"H, without cystitis, 
rectal 8up|H.>HitoneH (»f morphia antl atrupia at ni^hl to Fierure 
reeL The following is an eHicienl and couyeuieat remedy : 

B. Ext. buehu fld. 

Tinct. opii caniph. au f ^. M. 
Sig, — TeasiKiurdul (or more) every two or three hours. 

fJive blnnd nmeUni^imaisi drinkp f rtaxs»«'d tea. cold infufion 
of BHp]terv elm bark. ele. ), itdiisionp of uvn un^i. or trilieum 
re|>*»us, eond>iueil (if the urine lie over-acid), wiih lii|. potiissa 
or |«*ta.ss. bicarb. lialsani roiwiiba and linet. helhidoruui inter- 
nully may be tried. 

In evpliti*?. lieMdes the foregoing remedies, the eavity of the 
bladder nhould lie daily wnshtMl out with Htime warm autiseyitie 
solution, vi^. creoliu, li) dro]«i to a pint of water; or either 



ArFECTIOyS OF THE REPIlODVCTiVIC ORGAyS. 14'J 



thymol, snlicvlir acitl, or jK.ituss. jk ritiiiii^aiiaU^ in ihu |mt|Mfr- 
tion of 1 lo ioiMI r»f water, or Imric- aci*!, 40 to lOOO. 

In all L-a-Ht*! \w sure ilic lilaililer rf»[n]»leiely fmpti(»s itsolfl 
It' neoensary, use mule eliu>li(: ratlieter. Kej^hire the uterus if 
ili»|»laeeJ. The kiiee-fllxjw [xjsition amy enalile ihi' [uUient U) 
em|»ty the hiatlder. When the wonili iiirliucb forward, prees- 
iiijij U[>i>ii ihe ]»huiiler. push luK-k urul sup|>«>rt it \viih wiJe 
alMloiiiinal handage. Ke*!)) the huwelH free I'nan aceumuhUiou, 
thus leaving more room tor the uterus aud bladder. 

HKMATURrA — Bi.(MJi>Y UuiNE. — May owur from stone iu 
the bladder, in which eatie the calculus pilunild l>e removed by 
surgical it|>pr:uiiHi during the Am/ mtintft (if [ireLruaney, thus 
saviuf; the ciiiM tVuin the rink of premtitnre ljdM)r. ^1i<»mM that 
oeeur. Hematuria al.so results from ncnie (yt^litis mid iiejiiiri- 
tis and from prej<-iire of the gravid uterus proiluciug con)jej>tiou 
aud iliHlentiDU of llie bloudveiweU of the Madder — soealled *' v^'a- 
irnf hnnorrhoidri" lit lhi« lust ease iiemitrrlui^e may l>e suf- 
Hcieutly severe to reipiire iu<triugeiit inje<'tions into the blad- 
der ; and uterine pre**urei4honld l)e relieved l»y tlie knee-chest 
IKititure, or Siam (Kisitiuu. I^axativets if re<|uired. 

Incontinknck of Urine. — Small and frtHpienl involuntary 
disi'har^ei*of urine are ot\eu nssoeialcd with over-disteutiouof the 
bladdt'r and lossof tmir in its musrnlar widl. There may also 
he. fKireslh of tlie vesical sphincliT. The liow (tf iiriiie tx'curs 
during eou^duni^, Inutrhin^', sneeziu;:, eie., but also nt other 
times. It nuty lie produced by uterine diriplacementjd ; lK)th 
an teve ration, retDversion, au<l prola|«us. 

Trentmrui. — In cosefl of detieient muiw»nlar tone in the 
bladder jfive tinet. nueis vomica?; or strychnin; or tinet, 
ferri chloriil. for wnie davs or weeks. For n short/T time, five 
dro|)H of titict. eaiitbnrides in ."^j of HaxKM*<l tea miiy l»e taken 
I. i. d. Kre<pieMt ablutions and simple ointments may be r(v 
quired to relieve or prevent exeoriiitions of the skin. A dis- 
teuded bladtler will of course require a catheter. 

ArKKfTION'8 OF THE REPRODUmVK OruANS. PROLAPSt'ft 

Uteri (Fai.i.in<j oftiii: WctMU) T»t'RiNo PuEONANrv. — It 
usually rijrhlH it.S'?lf when the wond> rises during the third or 
ffMirth month, but, failing: in this, Ihe condition may l>eoonie 



i 




150 HYGIENE AND PATIfOLOGT OF PREGXANCT. 



Bcriuus Jroiii the growing uterus getting janiiueil between the 
bony walls of the jk'Ivk'* ami press^in^ir ii|k>u the lihidtler aud 
rccltnn, or Umiling to iiborlion. Tlie prt^sstire of the* growing 
uterus may even produce sloughing and K»>»'Krene, either of 
the woiub itself or of the organs in contat't wiih it. 

Treat mttit.—HL'^i iu the ret-uiiilK'nt |i<jsture, with the hipe 
elevate<l on pillows, punhing up the uterus by gentle manipu- 
lation, and, if imjKtnitively ne<'etJBury to keep it there, pi'ssii- 
riett. Continue treatnii'nt until uterus geU* large enough to 
remain above the |>elvi4* brim. Should inipaclion 04Tur and 
obmtruct di:*<*harge of rer-tum or blathler, the induction of alwr- 
lion niijy lKM'on»e u netreasury rei*ort to save the womnn'8 life ; 
and if the tifitiues of the womh be infected the entire urgau 
should \h£ K-moved by vaginal liyHtere^^loniy. 

KtTROvuRsiox OF I'tkiu's. — Tlie fumlusof the or^an falls 
over bnrkward, while ihe eervix in tilk-d upward and forward, 
toward or over the pubei?. 

Stfmpioim. — I'aiu in the back, mindnicsH or prieking or 
unsteadiness in the lower liiidw. and dittienlt or very fminfid 
defecation and mieturition. The iliagnoKis is made on finding 
the fundus uteri in its nudjMiHition by a digit^il exannnatiou 
jiir iijffiufwu while tiie os and neek are tilUnl high u|i toward 
the pubew. 

Prog}io8i/t, — rsually favorable from gradual 8|KmUiiieon8 re- 
plaeement as the womb inereaM'i^ in size, but serious or fatjil 
con.s*M|uenres may ans<^ from impnrtion of the crowing organ 
(as in prola|T6U8 ) if it be not replaced during the earlier months. 

I'lceration and slouLrhin^ '»f ll>e bbidder may wour from 
prolonged retention of urine with eonseipient urienua ; and id>- 
struction of the Iwwel may <'ause ahst>rptioii of pois^ms from 
the iiitefttlne and const^tpient toxiemiti : the bowel, vagina, and 
bladder nmy ulcerate or rupture from pre.>*sure, and {M*riti)nitis, 
8epti<'irmia, and pya'mia follow. 

Trcutwrnt must not 1h^ dehiywl. Empty the blft<lder hy a 
male elasric entheter. If ihi-n be imjM)SMible, aspinite the blad- 
der. In using the catheter it should be reinendiertil that the 
urethra is sometimes f/ojtffaitd to the extent of tour or Hve 
inches. Empty the re<;tunK I'lace the wonuin in the hnee- 
elbow iH}/titioti^ and restore the organ by gentle digital pressure 
either by vagina or rectum, or Itoth eoiijuiutly. 



n 



BETROVEnSfOX OF CTEnVS. 



161 



8houl<l niiinjpulii(i(»n iUi], iniiki' gtntlr, proIoii^'tMl [irfsstire 
by (listeiuliiij: u sott-rublter Im^ in the va^'iiia, or a Barnes' 
dilaTor in the rettnin, tla* jjrt'ssiiro ilius iiKluctil he'u\\;: kept up 
for several hoiin*. Alter rei»lueeniem a H(k1^'c jiesi-ary may 
be ref.|uired to retain llie womb in Us imrnuil |:tiMtii>!i, nr tam- 
ptms ot* ahtiseptie c-ottou plaocil beluint the rcrvix in llie |>oe- 
terior vaginal toruix may be used I'ur that purpost-. 




i:t!ln»rtinlun at nUtniX Iwtlfth Mcuk. 



8honl(l all moans fail in pet the funihiR above tbc Faeral 
prrnnont()ry, aliurtion or premature delivery may be required 
to sjive the wnman's life. If the ntrrine litsins are inHanied, 
aleeraling, or ^':ingreiiou». va^rinal bystereetomy should he 
done. 

Fi^. (>H, from f^iFhrnati fnfter S^'hultze), nhows retruver- 
«on of grnvid wond) at about twelfth week, with retetition 
of urine and ent»rmot;8 diHleiilion of bladder, owin^ to the 
urothrn being dragge<l up anti eimipressed by the disphieed 
oerviz uteri. 



lo2 JiyOIENE AyD PATHOLOGY OF PHEO/^ANCV. 

Retnivereion of the ut«nw w frwiuoTitly a.swMmte*l with 

some decree *it' r{iln>-jii'.rion — h iK'JMliiii: aC the nxis of the 
womb, ill wliich the o.s extvrmiiu ami viigitml |x»rii<>n of the 
cervix iipjieitr Ui niainutiii their iioriiinl jHjtijiioti, uhile tlie 
fundui) IS licni Imckwanl towunl the sacrum (Fig. H!)j ; Imt 



Flu. 6». 



i'] 



RMro-jtei/ofi nf pravld uteran-flixtcviitli wcc-k. (ricittitns.) 



the (IiH;Liliou.fl resuh* are the game fts in wmple retroversion; 
so \^ tlie treutinent. 

In the case of retrollexion it (K'<'a>iioual]y hainK'ni* that the 
womh )kmh)iiu%i (iilattvl into n itort of douhte siu', one |M>u('h of 
it 1>ein>; ulHtvu ami the other l>elow the |)eivio liriiu, lUt shuwu 
in Fijr. 70. inun Dr. Barnes* work. Impaction, tuiil ihin- 
gerouB preasurt* ii|Hin l>lmhU?r. etc.. in the |x*lvir caviry, are 
thiw reiicve^I. liitfh j>onrhi'« may also rine nlHive the l»rim 
8(Mmtane(>uslY a8 preirnanry pn»eee<K an<l the ^reslatioii reach 
full term ; or. the Itmi-r poorh remaining' in the i>elvir cavity, 
full term may still l»e attained, but delivery \s, im[>o(wib]e. 



ANTEVERSiON OF VTEUVS, 



153 



owing \a^ displacenxent of llie ns aI>ovc ]»u1x«, and occuj^tioii (if 
ihe pelvic cavity by the lower imjucIi, uiilf.-:^ tlie lullir In- ()ii?luril 
U{> by manual prt^ure per m'juutm aiul the os uUti hn^u^'lit 
down, which 'm the prupcr treatiiicul, during both preguauey 



KlO. 70. 




BlBHrenlntvil moru«— inromplcto rt-troflejtlon. 
It RtK'tum. or. Oi uUtI. D. Urethra kriI bladder. 

and laUtr. SlKtuld \\m method tiijl, the hu< rtwirt is va<riual 
liyi4erotoiiiy and extraction of the rhild through the iuci^iun. 

AxTKVERsioy or Utf.rL'k. — Sin^v the anterior pelvic wall 
in only one-third an deep nn the iMLstcrior one. there is far le«» 
dirticulty in llic fuudnn uteri pettinp above the brim when it 
is diH]>laet'd anteriorly (anteverflon ) than when retroversion 
(MTiira, Hut when tihitvf the lirim the wnnil) may still remain 
anteverled and pre,ss n|w>n the bladder, as fxrurs chiefly in 
deformed women fj>elvie deformity i, or in vrne^ of ventral 
hernia, or in tho«e whom? abdominal walN have become relaxinl 
and |>enduh>u» from fretpieut rhihllM^aritig. 

DiafftiOiriM \» made by vapnal examination revealing the os 




154 IIYGUCSE ASn PATHOLOGY OF PRKCSAStY. 



atitl cervix uteri fhr Imck, while the fumltii*, thrown lurwnrd, ia 
felt thruugh the anterior vn^i^inal wall. 

Anteflexion of the womb — Itcudinr^ of the uterus so that 
the fundus amllMKiy are curve*] forward toward the hladder 
aiid pulH'j* — may or may i»ol he ai«>fiatetl with anteversion, 
juMt dw»eril»e<L It w apt to oecur iu women wlnu^ uteri were 
antetlexed l>efore pregnancy l>egau. liarrfy the fundus may 
l)e<?ome locked behind the puW, hut it Ls far more easily re- 
placed thau retroflexion, the pubic L»oue» olfeiiug uo prujtHrting 
promontory like that of the Bacruro. Ketvutly, however, diffi- 
cult cades occur from the auterior wall of the uterus liaviug 
t>een fijted forward (before imprej^ruatiou ) by the operation of 
stitching tlie fun<iut? to the alKlumiaal wall for the relief of 
retroversion. Wh^n such *' anterior fixation" vi' the uterus 
Ims l»oeu done, tlie enlartremeut of the irravid «)rpin pies on 
chiefly by expansion of its jitMsterior wall, while the auterior 
wall, tie<l down by adhe@ion£i« remaius thick aiid UDex{]ftii4leiI ; 
hence irreducihie auterior displacenieul. 

The symptoms are : irritable bladder ; frequent micturition, 
increase<l by the erect pojsture and niiti^ratc*! by rt cundiency. 
Vomitinj.' excessive and lroubleji<>n)e. I'ain in the hvpojrastric 
regrion and ptdvic cavity. Diapiosis by the name means as 
07ii<?trrWw7i, except that in anterior firxion the oa and cer\'ix 
may retain their nonmt/ |M)c<itlnn. 

Tnotmmt. — Kefilace the womb, in ejisy vaee&, by diptal 
presure upon the uterus through tht* aulurior va^iual wall. 
Rest in be<l, on the ba<'k. In «iKeft of weak an<l [leudulous 
alxiomiual wall, put on abdominal binder lo siip[«>rt the womb 
from tilling forward over the pubes. In diflicidt cnpcs with 
anterior adla^ion^, use |>ersi»tent digital iiiassiage and vaginal 
tampous, to stretch or break up the resisting adhesions. 

LKr<<)RKii(FA, r»R "Whites," — It consists of an exrtssive 
discharge of nuuuis from the vaginal canal. It ih liable to 
irriliite the vulva and |iroduce itching and ex<*f)nation. Ton- 
dyloniata may exist, or granular |mpillary pritjtMnioiis consti- 
tuting graiuiiar vaginitis. Generally the iliscjise is simply a 
hy|>enfte4'relion, due to congestion of the vaginal wall or cervix 
uteri. It may be due to gonorrh<ca or to endo-cervicitis. 

Treatmetit, — Avoid the use of injectiops for fear of produc- 



PRURITUS VULVM. 



155 



in^ al>ortiun. Frequent te|ml emollient nhhitioiis are iudis- 
|iensal>le for olwinliiifKs ami Ut prcs'eut excuriations, eta 
Ijiixatives to prevent ('onHtipaiion. If the (lirW'Imrire 1>« «utfi- 
ciently protiwe to rfquirr luoileratiiig l»y astriugcut, use vaginal 
suppositories of tannin^ attini, etc. 

U. AoiiL tannic ^j ; 
(.)!. thcobrom. q, s. 
Fiat 8np|)08. no. vi. Use one twice daily. 

A mu)*lin baf». Inrjtre enough to contain twenty grains each 
of alum an»l hismulh subnitrute, may Ik* introiUutnl tlry inio 
th^ uppt^r part of the vagina, and witlwlniwti hy its attached 
string after twelve houn*. 

Insteiid of ajrtrinirents, a single ap[)!i('at)oa of a .*^0 per 
cent, wjlution of carUilli: acid in glycerine may be made to the 
vaginal mucon.* membrane and cervix uteri. 

In gonorrhical caries apply a '1 yter cent, solution of argrntit; 
nitnito to eirnj fntrt of vaginal mucous metidirane, witli bru.^h, 
through S|>eeuluni. daily. Keep the parts clean witli mild 
bichloride of nuTcurv lotion. 



Pruritits Vulv^ — Intense itching of the vulvn is of fre- 
quent (K^cmrrHiice during pregnancy. There is un irresistible 
<le^ire to rub the |»art.M, sometimei* even (luring nleep, wbirh 
may lead to excoriation, wnbbiug, uk'cration, etc. Itching 
mny extcud over thighs, alxlomcu, an<l other |>arta of the 
ImmIv. 

Usually eauard by irritating vaginal di.*icharges with laek of 
cleanlinosH, but nuiy he a pure neuntesis, (.tlycvwuria and 
|iHrut(ite« may pro<luce it ; alw) ingrowing hairs. 

Tf'rMmrnt — Frequent tepid emollient alilutiona Dust the 
vulva afterward with starch |)owdcr four part^. to pulv. cam- 
phor one part ; or jxjwderod zinci oxid. ()lher remedied are: 
a iflolution of eorn*pivc Kublinuite, gr. ij. to water %] ; solution 
of wmIiv bornt, .y, to water one pint ; infusion of tobaixN) {"^^ 
to water one pint) ; a|>)ilieatioii of essence of pep[»erinint with 
a camet-hair brush ; or a lotion nmtaining Iwrax ^ij, oil of 
|)epi>ennint gtt. vj, to hot water one pint ; sulpho-<'nrb«»late of 
«iuc .\), lo water one pint : carbolie arid gtt. x, with glycerin 
and water, of each .^sii; an*! dilute hydntcyanic acid ."ss, with 
acetate of lead ^ij, tu water one pint. I'aitit the parts with a 




16C HYQIE^B AND PATHOLOGY OF PREG^AiiCY. 

4 j>er cent, iiolutioti nl" liy<lriM:h]orate of cocaiue. 
lowing oiiitirn'Ml niny l^io sirvicouhlc : 

VUui'A liy.lral,. \^'^^'* 
I'ngl. iHiiue rdp*;)', .^ij. M. 
If uluere exit*t, remove »eal>H hy wnrin poultiti^, then apply 
nitraU' of silver gr. xx, to water .y» to l>e followeil by ealoniel 
niiitiiieiit (=y of eaiomel to ,^ of viiBeliiie). 

Painful Mammary Glands. — Breasts are the Beat of pain 
of a ueurulgiu rhanieter, due to rapid development In ple- 
thoric woineu relief may Ihj obtaine*! by the derivative effect 
of ssaliiie laxativei*. In au;enii(', rtentiitive, nervoiid women jrive 
iron, quinine, wine, and good f(>od. In either cax- application 
of heUailntina ointment, or the tiuciure j*prinkled on a bread 
IH>ultice, or uiuHlyne Hnimcnt-s of olive oil, camphor, and lauda- 
num, will iiHbrd relief. 



D18EAHKS OK THE BUK)D AND CIRCULATORY OrGANS. 

pALi'iTATioN OF THE Heaut umv occur either sympiitheti- 
cally iluring the early monlltf, or later from encroachment of 
the enlar;;e<l uterus pushing up ttie diaphragm, and e.mlmr- 
rafiftinff the heart's action. 

Treahnt'nt. — The »ym|mthetic trouble ia UBually af«ociated 
with nervous delulity due to ana-miii, and therefore rw|uire8 
iron, quinine, ^(xmI diet, and n little wine. A plaster of bella- 
donna over the cardiac re^rion. Din-ct relief may b*- ohiained, 
tem|M)rarily, by lusafoititla, liyuHcyamuhi. and other auti-ts[>as- 
nuMlics. 

The oppoiiite Htjite of plethora may exirt, when rest, hixa- 
tives, low diet, and, j>erli{i|ts, bloiwlletlinir will be retjuired. 

For the niechani<'al enibarriitvfmMiis of the later nutnths, 
little can 1)e done further than palliution by antispiiMno<li<s 
and nttf^ntion to the general health and excretory functions ; 
but the patient may be cunsoled with (he asHunim'c of relief 
when the \v*mih sitik> dnwn prior to delivery. Temjwniry ease 
may l)e attained by be]la<lMni»a plai*ter8 over the pnecordium. 

Syncope, or Faintino. — The attacks may recur several 
times a day. The pulw is feelile, pupils dilaleil, consciousness 
partly loet. and there may l)e hysterical phenomena. 



Ay, EMI A. 



167 



Treatment, — RecunilH'ncv wilh the \\^m\ low. the appHcn- 
tiou of ammoniii U» tlie imstrils. ami ilttiui^ilik' tliniulunts, 
valerian, dr., durinj* llio lUtnckH. In llic iiitervuls. iron, 
fooJ, aiMl hitter tonir*. Hroiiiitlc uf jRitnssiiim ^r. xx ihrre 
tinu« ii <iay. Itcinove <*orstt.s ii^'lil-filliii;r flutln-s, and all 
Iwlta, waist-Hlrings, ami hti'liy-lmuiiH. Avoiil crowded rooiuB 
aud impure air. 

Anjesiia. — The txacf hlood-<'haugee of prepnaiicy that oc- 
cur //onno/^// are still uiisctlliHl, lull the temleiu'v pciiernlly is 
toward amnnlu^ which may hei'iMue wi j)rniiouiu'e*l na to re- 
f|iiiro IreatTncnt. It is rmii^t ii|it to *MM'ur during llu* Inter 
iiKUitiiH. when the red eiirinij+t'lfw and nlhuuiiii uf the hlood 
are dimiuished iiu<l its tihrin inerciiHed. A few jhUif eiiK'S 
have lieeii recurdetL The i*}{}ujttowM are those eoninion li> 
ana'Tiiiu iu other eases: palUfr, Ins-j of apjielite, feehle and 
fre*|nent |>ulw% weakne:**, and fatigue aiVer »*li(rht exertion, 
nerv(»UMio«, eiuolioual exeiiahility, imlpilulioii, Ti['urid;jiu, etc. 
In Kome east?* there w-eur : vertijjo, tinuiUiH auriuni. HuHhed 
faiv, fulntHS or weijrht iu the hen<l. ami stujiiioli'iiee, which 
niijrht, without care, be nnntjikeu for m tnpt»>ii:8 of plethora. 
Ill other iiLsianees the IdotHJ he4*onu's .Mt thin and vuiery hh to 
coimtilute a veritjtide hutlnrniia, when o deniii and ilropsy nniy 
o*'*'ur beginning iti the IW't and extt*iidiii|r i*ueo(si*ively upward 
to the lep», thighs, vulva, viifrina, and uterus. The hthin niiiy 
bwome enoniiou-s in Hize, the a'deniatous diHtentJou even lead- 
inp to panprene. 

TretttmaiL — Iron, the rjunntity of which in the blood, 
owinp to lo»i nf red blood-eorpuwles, is diminished, a? proved 
by anulynii*, Prn'eile the administration of iron by laxatives, 
t#»pid baths, sutislane. pure air. and outdoor exercise, to pre- 
pare the system for its reeepli(ui. Iron is oflen not well 
i)orue by preirmint women. Its solid pre|r(iratiniis — the ear- 
iMinatc. the imn by hydni^fcn. or the ferrum rednetum — are 
preferable. They may be e«rnd>inid wilh bitter tonics — the 
ftolid extracts of cim homi, ^^entinn, etc. — or with laxatives — 
rhubarb or abx-s ; and with (piinine or arsc'uie, or nux vomica, 
(live n itmtt diet — lean, underdone lM*ef, or Kcnii>c<l lean. m\r 
iMjef; tojretluT with milk, or beef lea, ej:p*. and some red 
wine or bitter beer. In hijflrtniiir caw* the nrlpmatouii labia 
may re(|uire nmall |Minetures to let out the fluid aud relieve 



168 HYGIENE AND PATHOLOGY OF PREGNASCY, 



distootion (always with antisieptic dressings), and recun»V»ency, 
or elevation of tho lower extremities. 

CuRfts »MX.iwiotial ly *x'eur of f*enii(.'ious iiniemia with leukaemia, 
which, if not inipntving under treatmeDt, may re<]uirc the ter- 
niiiialiuu of preguaucy. 

Plethora. — Plethora duriup prepnancy is nire; it may, 
however, oceiir, or i*inipiy constitute the continuance or iu- 
crcaae of a pro-exiiitin^ plethora. The i^ymjiioinA are opjKRiiLe 
to those of aii:eniia. fXi-ept with regard to hca^laclus ^iddi- 
DeHR, fliisliinjr of the face, nnd nnp;iup in the ears, which may 
occur ill hoth ; hut the general ap|H'arancr »)f the female, 
to|;ether with, in plethora, the siren^th, fulness, nnd ^lownesd 
of her pulse, will render dii4:uosi.s e^itjy. Mnuy plethoric 
women present a previous history of profutte menntrualion. 
Uterine hemorrhage durin^c jrcstiilion, and coiirte<|uently alior- 
tion or prematllr^' lalM»r, nmy (wrur, unU-ftt* relief l>e atforded. 

TreatniftiL — Siiline laxatives to produce watt^ry evacuationH 
and thua k-sstMi vjwrular tension ; or a more decided t^thartic 
to W'ijiu with. Avoid animal food, meats, eggs, nnlk. as also 
highly seasoned disht's, condiments, and sLimulaut.s. Kestrict 
the iptautiij^ of foo<l, and let it wmsist chietly of vegelahles, 
li^jht fl()U|is, and coolinp drinks. Immediate relief may Ih» 
afforded by bleeding, even though the (quantity of bliMKl taken 
be ((uite nHKlerate. l,^ee<*he.s or cupping will lie preferable 
when, cuupUnl with genenil plethora, there is IochI hy|)enemia 
of some particular organ, a^* the brain, kidneys, or uterus. 
Sexual exeiteineut aud c^iitus must be prohibited. 

Varux)8eVkinh, Hemorrhoids, TunoMBrs, srra — Press- 
ure of the uterus u|>ou the large venous trunk« cauH-s disten- 
tion ami varictjse dilatation of the venous brancheii l>elow 
them. Hence uedenia and varicose veins of the legs, heinur- 
rhoids, dilatation and rupture of the veins of the vagina and 
vulva, with extermil blci'diiig, or formation of thrombi. 

Treatment — Kest in the retumUciit [Ktsilion, supjM>rt vi' the 
uterus by abdominal i>andagej*, sufijKtrt of the veins )►(' the 
K*gs by elastic sttxkings or well-iip|i]ied roller banilagea, 
Rnfittire of a varicose vein may (Kvasion fatal bleeding; 
hence supply the [mticnt with coniprcNH and baudage, and 
teacJi her how tu tiAt- them iu case of need 



DISEASES OF THE RESPIRATORY ORGANS. 159 

Hemorrhoids require, in addition, laxatives to correct con- 
stipation, cool-water enemas before stools, and the avoidance 
of all straining efforts. Cold ablutions to the anus, followed 
by astringent ointment, ex. (jr. : 

B. Ung. gallie, ) 5. ^ 
Ung. stramonii, f **** •^- ^• 
Sig. — ^Apply to anus, inserting some within the sphincter. 

The Ungt Gallse c. Opio (B. P.) may be used in the same 
way with excellent effect Bu]>iM)sitories, each containing 
iodoform grs. v, ext belladonna gr. »s, glycerine ay, are both 
soothing and laxative. The couftK^tion of sulphur is a good 
laxative in these cases, and, contrary to former experience, 
aloes has been found beneficial, as in the following formula by 
Dr. Fordyce Barker : 

B. Pulv. aloes soc., ) -- -v- 

Sapo. cast. pa £^J ; 

Ext. hyoscyami, 5S8 ; 

Pulv. ii>ecac. gr. v. M. 

Ft, pil. no. XX. 
Sig. — Take one night and morning. 

Thrombi of the vulva or vagina, if small, may be left to 
nature for absorjrtion to take place. If large, causing press- 
ure on surrounding parts and threatening rupture, the only 
treatment is free incision and careful removal of the contained 
clots, followed by antiseptic washing, cleanliness, rest, styptic 
applications if net.^erJsiiry to prevent the recurrence of future 
or stop existing hemorrhage. The progna^is in such cases is 
doubtful. In all caK's abs4)lute rest should be enjoined to 
avoid the occurrence of enibolifjm. 

Di8KAHF>4 OF tiikI{i><imkatorv Or<jans. — Thoso comprise, 
chie^y, functional (lifturhain't' of the ntfpiratorif aefA, manifested 
by two symj)toms, viz., cotKjh and fht/<pii(ia. The acute and 
chronic ortjuiiir disciuics, |>neumonia, pleuri.'iy, etc., occurring 
withy but not on account of ]tregnan<'y, may Im? oxchnleil froiii 
simple functional <iisturhanccs by the ab.^'nce of their charac- 
teristic jihysicnl signn. 

Coiiyh and difupnan <M-cur during the e^irly months as ner- 
vous or sympathetic troubles, when they rtKjuire anodyne and 



160 JiYCTEyE AND PATHOLOGY OF PREGSANCr, 




pnlliative remedies, rounter irritations by siuapisma, reflex 
B€<iarivt* (rt)tnbly the bromides), and anuppamiuiice — valeriaa, 
eninplutr. riMir]>1tia, dilute hydrocyauie acid, etc., us in the fol- 
lowing c'ond»iiiatiou : 

H. Elix. amnion, valeriauat. 
8(>tK ictlieri:^ iiitrubi, 
Liif. morph. siilph. 
Aeid. hydnK'vanir, dihit jrtt. xij ; 
Aquio cuniph. ad 
iSi*;. — Tahlfti|xx)nful every four hours, until relieved. 

In ca*ies id* oMinate and |»enHstent coii^'b. ten drojn* of the 
oil of saiMinl-wocxl pvpo with a destiert.<|MM»riful of the entuUio 
aniyplalic, thrt«e tintw* a tlay. will tometiuies* aironl relief, 

I>iiriii^' ihe later nioutli;* couirh ami dyj^jintpa result frnni 
the enlar^red ulerufl encroaehiup upward upon the diaphragm, 
thus interferinif with a det-p inspiration, heiite the l^reathin^c i» 
Khalluw, fre<|iieut, and uiu^atit^iyinj;. Thit^ is mottt oliservahle 
where the wondi if vny latere, frum twints dropsy of the 
amujuii, etr. Trmimnd by pallialives, ah in the M*nipatbedc 
cacfeH, but with little a^^urauee of hucc^'H until the wuinb nnks 
down before delivery, when we may antififwte sj»ontaneoU8 
relief. l^xAtivee miti^^te the i^utferiiig. 

Ki:RVfn:p Disi:Ast:s. — Kxajrjrerations of the mental and 
emotional phenomena alrt*ady refern-d to ait sign? of pn*gnancy 
may occur. They lead us to apprehend in.saniiy. The time 
of their nioj*l frequent occurrence ii* from the thin! to the 
seventh month. 

Trtntmmt oonrfots in the promotion of ftfeej) by bromides 
an<l chhtral hydrate ; laxativei* ; imKlerate exercise, cheerful 
society, and chaupe of scene ; together with attention to diet, 
and the profier digesliou and as^iiniilation of footl. 

Chorka during pregnane}^ \» ran*. Il t»ocurp chiefly in 
ihow who have previously suflered fnmi the di.«eai*e, and 
mo8tlv in priniipara*. Ita eaiisf^ (admitte<ily olif(cure) embrace 
bere<litary preditf|>oKition, the heart leaons of rheumatism 
and conscfpient endinlie pro<v,««\s ; anaemia, fear, wtrrnw, 
anxiety, and |ieriplieral .«exii!\l irritation. It if* apt to begin 
coincideDtally with the early fu?tal movements. Il is a serious 



GESFMAL IDIOPATHIC PRURITUS. 



161 



complication, gomelinies ending in insanity, premature laljor, 
an<i, in about one-ihinl of the. r^sei*, death. The child ia 
sometimee uHeutetl svith the disea^^e. 

Treatment. — The hroniides atid chloral to produce sleep and 
le^^icn the movenieut& Mental quietude : re^t ; avoidance of 
excitement; chan(^e« of ncene mid pleajiaiit niirruundin^ 
ArsfMiic, ir(jn, ami hitter ti»ni**s. SKliuin siilit-vlale in rheu- 
matic c:ue6. Aa a luijt re;*ort iodutiion of premature lalmr or 
abt»rtion. Prior to the latter |tro(^e*'din|^ moderate digital 
dilatation of the os uteri is northv of triul. 



8t'iATiCA. — Pain in the |>elvi.s i^hotitiuL: down ihe thi^b, 
sometimes accompanied with eniiiip. and tende^u-^^ on pre^8- 
ure over the sciatic ner^'e, are usiUiilly due tit constipation and 
preieure uf hard fe<*al accumulation. May al:^ tKVur from 
uterine dirfi>Iuceinent — notably retroversion — and from Uxe 
pre«Hure of a larjje and heavy child. 

Treatmnii. — Laxatives' intenially, and large rectal injec- 
tions containing ca:stor oih tur|>entiue, Boap, and glycerine, 
until the bowel is completely empty. Hulieequently, glycerine 
gupp<ie*it<)rie« and the reme<lier* previously recommendeil for 
C4)n.stipation (see page 140). A di.»*placeii nleniH rnuHt be re- 
placed and retained in iMwititin (j.:»e (wige 150). The pressure 
of a large child can oidy 1h* mitigatecl by the hit*?ro-prone 
poeture, and loose clothing, together with anodynes. 

Paralysis (hemiplegia, paraplegia, facial |»alsy, or paral- 
ysis of the organs of the s|iecial sensefi) mx-a^ionally occurs. 

Determine by urinary analysis whether or not the symp- 
toma are due to the retenliitn of urea or the presence of some 
other toxic agent iu the bltKHL If no the main element of 
treatment will l»e by increased elimination — purgatives, dia- 
phoretics, diuretics, etc. These failing, the question of in- 
ducing premature labor must be comiiilerefL 

General iDiopATiiii' I'RURiTue. — A distressing and norao- 
timefl exhausting nervous trouble is a general itching of the 
skin, without any visible lesion or eruption. In very nervous 
women it may lead to abortion. Js apt to be worse at time* 
rorresfionding to menstrual peritrflp. While difficult of cure, 
it endi with the termination of pregnancy. Palliative reme- 
II 




162 lyTKRCURKFiXT DISEASiCS OF PHK(tyANCY. 

diM are: inuDOtion with vaseline after a pmlonge*! soda-lmth. 
Appliwitioti of carlxjlir acid (3J lo water Oj); or lin. saponis 
cornp. ,5V, willi chloroform .\i, applied on cloth. It has \teen 
1'un.Ml hy i*ninkin^^ o ci^nr. Solmiotis of rhloral, menthol, or 
ct^irrotiive sublimate may be tried. Also liuseed oil and lime- 

WUtlT. 

Apart froiii this nervous itching without any skin lesion, 
actual hf^i'juM niuy mn-ur (hfrpt/' tjtutfttiouii*), fiud return with 
succeeding prepnancicH. Patches with rednw**. i*onie with large 
hulhf, ap[>t'nr on the hullix'ks. abdomen, thorax, feet, and 
forearms, together with itchinj^ and burning. AH'ecttf yuuug 
women more than others. 

Trrntjitntt. — I'se wime palliniives ah reof)mniended above 
for nervous pruritus. When eruption bej;iiis armiut with 
Vxjrated vaneline or glycerol of ntarch ; and when eruption is 
fully dcvelo[K'd (bint the surface with j)owder of bismuth and 
Kiarch, tir Hian4) and talcum. Baths I'oni^iiniu^ starch and 
bnin are bencfK'ial, Touits, laxativcH, and diuretics majr be 
a<lvi«able. 

Another skin trouble {pibjrumn grandantm, resembling 
pitj/rinttift rerfirolor) oi-currinp in feeble women, and diapios- 
ticjite<l from pitriiienlnry ile]H>sits bv finding the characterintic 
parasitic i'uii^ri in the H-alcf* nji*THf*<t»pi<,'ally, can Ik* relieved 
by waiihiuii; ihoriMiirhly with tincture of green soap and ap- 
plying vcnilrin, grw. x, in alcithol .^j. 

Chhutxmata: Itrown |mtcbcii of pigment upon the cheeks 
and forehead, with darkened rings under the eyen. Arc not 
amenable to treatiueut, but di^upiH.'ar »[ionUueQUsly at^er labor. 



CHAPTER IX 



TKTERCVBRENT DISEASES OF PREGNANCY, 



A pRK<iNA7iT woman may he attacked with pneumonia, 
meafiles, »mall|>ox, etc. Such disen^'p, while in no way ffve 
to pregnancy, oc<'nr as accidental eynnr-'nimrrji seriously com- 
plicating it. The prognosis and nsults of such cases, with 
rogard to tlie pregnancy itself, and to the life or death of the 



TYPHOID Ay I) TYPUrS FEVER. 



163 



mother and ftrtus, ami the rules for treatment, will here be 
hrierty otiiisititTtMl, without atteniptiog any couipU-te clest'rip- 
li^in of file dii*fflsei* themiselves. The arute tevei-p — ninlarial, 
coutiitued, and fpupiivt- — constitute an iiu|)ortant grou|i of 
thfse diseai*e» first L'luiiuiujr our ntu-nliun. Tliey nre all at- 
t^-nde*! with ftifjh tanpn-ottire. (Vintiuucil hi^'h tenijierature 
aeriously irnjwrils the life of the firtiis, and, in eoneequence, 
the rontiuuance of pregnancy. PVtul life is furtlier endan- 
gerefi hy changes in the composition of the mother's hlood 
and in the maternal itliH>d-|)respure — the phu'cntnl eirenlHtion 
being thereby impairtd. The child may also be infected with 
the mother's tiinease. 

IvrrRMiTTKNT FKVKit — A(U*K. — Pregnancv i? not, as was 
onoi* i*uj»iKi!*ed, a nroteition against apue. Not oidy may the 
niollier have it, Itnt alw> the child in vtero, the latter being 
Iwru with enlflrjjed spleen and tither evidenooji of tlie diwase 
in eonHe<|nen<v. In many cjisics premature labor occurs; in 
a small nuinlKr. uKirtion. The foetus, if not dead, is often 
feeble and ill-nourishetL 

Trrtttnu^tit. — <Juininc» or arsenic, as in cases without preg- 
nancy. The feur of (piinine protlurliHj abortion may be di»- 
misstn] ; the dis**a«' is niuch more to lx» feared than the me<li- 
cine. Women in malarial iiistriilif who esca|fe ague during 
pregnancy are liable to it after lielivery. The attacks may lie 
previ^nieiJ by giving quinine during a few dajTs following par- 
turition. 



Rei.apsino Fkver (" Famine Fkvkr "). — Nearly all preg- 
nant women attacked with this fever abort or have premature 
lflU>r. Abortion is mt>st inminton. and in attcndeti with danger 
of great hemorrhage. Hemorrhage from the uterus may pre- 
cede, and then contribute to produ<*e. the abortion. 

Trrtttment should lie es(>eeially directe*! lo the control of 
this hemorrhage before, during, and after deliver}'. The 
treatment of the fever itself should Ive essentially the same as 
in case« not citmpHcate<l with pregnancy — care l>eing taken to 
control elevation of tein|KTnlure. 

Tvptioiit ANi» TvFnts Fever. — Typhoifi fever during 
pregnancy is rare. \\'hen it does occur, abortion or prenia- 



164 INTERCVRREST DISEASES OF PREGNASCY. 




ture lulior is fre<]iient. In Ujphns fever only nlM>ut haU' the 
wumen ttlK>rt Tb«^re ii* less <lniiy:er of ut4*rine heriiorrhage in 
t>'phii!i than in lyphciiil. In l>otb difteoitf^ the chihl i.s liable 
to be fe«ble, or ilciul, or it niuy ilit; with syinploiiii* of the 
mother's fever wilbin a few (hiys. The nmirol of ut<?rine 
hemorrhage and of hi^jb temperature e<tiH*lilute?' (he >*pccial 
element of trettlment, \)t^\t\es the remedies e<mi!i:imly achlressed 
10 these fevern when untximplieaieti with gestation. The prog- 
Q(m», as to the niotber^s life, is grave, but the majority 
recover. 



Yei.t-ow Fevfr. — This is a mos^t dangerous roniplicalion 
of preji^ruaney ; not less than two-thirds of the women die. 
Pregnauoy atTctnli* no immnnily from the di^ase, and |>artu- 
rition incrwu-^'s the habilitv as wtdl a.** the danger. Abortion, 
and <-<in«!qtjent hemorrhage, si]p|ire.'*sion of uririv, and anemia 
are the rhief t-aiHes of mortality. In wuierf that recover, and 
without mif^rarriage, it i.s said immuuity from the dieeoM is 
conferred up^n the otli^pring. 

S<;arlet Fever. — This i» more liable to occur during the 
puerperal state than during pregnancy, when it is compara- 
tively nire. Uoth romlilioiia add gr^atlv t<» the mortality of 
the disea**e. (iroat liability to aUirtiou i»r prt-mature rlelivery 
— liability varies* in diH'erent epidemitv, owing, ]>rol)ably, to 
the varying type of the }>revailirig diwaw*. Lving-in women 
expoi«od to w^rlatinal infection develop a nnxliticd tbrra of 
puer|>eral fever, attended with fjeritonitis*. <*lhjlilis, am! great 
mortality, C4ille<l •' Puerperal S<*jirlatina." During pregnancy 
scarlatina is a grave complication, tK>lb from ahortiou, aud 
from the kidney trouble of the fever adiliug to the atbumin- 
uria aud n^nal troublt^ i»f gestation, pHj^ciidly in primi|>arfB. 
In some cases pregnanry cotilinues, bnth niotlitr and child 
recovering without irvjiiry. Chiblren are somctimctii born with 
dei?quamation of the cuticle and ntber evidences of having had 
the disoa.-Mi in utrro. 

Trt^atment. — The same a« for scarlet fever iu the rH)n-gravid. 
As a rule, pregnancy should not l»e artiticially terminated ex- 
C4^pt, perha|)»i, in bad ca^^ of Hlbuminoria and unemia. Sime 
obstetricians advise it to save a viable chilil, when the mother's 
life is ID great jeopardy. 




CHOLERA. 



165 



Measles (RrRKf»i.A). — Very rare during pregnancy. 
Liability to alwrtioti. The child nmy be born Iwarinjr the 
eruption of uieiu«les. r»r d*^v*'h>|> the disease shortly art^ir birth. 
IIj* death in iittro i?* sup|«istMl lo he the t-biet' rntt^f of the 
alwrtion. Danger of niftrnrrhniria (if aborijon (Hrur), which 
may lie fatal !o Ixjlb oliild uml panTil. Kul^eola (hiring the 
puerfH^ral state in I'rtMjuenlly (.■oinjilicated with pueuiuouia — a 
complication of cousifleralile danger. 

Smam-pox (Variola). — Cmtflu^U snmIl|M>x nearly always 
Cannes alH)rtit>n or premature delivery, and is mmrly always 
fatal to the mother, the danger inereiu*ing with the advance 
of pregnancy. 

In disrrefe sinall[)ox also aburtiou is very IVt-qneut, but lets 
so than in the eontlueut variety, and the mother nsually re- 
oovers. The child may be Imrn with or wilbont the diH-'Ose, 
and, in some cajJtss, with pil8 or scarw indicating its having 
pofeed through it. Exceptionally, the child may have small- 
pox and the mother imt have it. lu twins, one child may 
have it and the other ef«ca[>e. 

AlM>rlion h^ liable to \w attended with profuj^e hemorrhage. 
As a rule, the child, whether viable or not, it^ l)orn dead. A 
very few survive. 

Every pregnant woman expoeed to variola should be vac- 
cinate*), utdci»c* protected by previous vaccination of recent 
date. A ret^ently delivered woman, iw a ride, shnuhl not be 
vaci.*inated ; tlxiugh it may be justifiable under circumstances 
of great ex|><wurc to a very virulent contagion. As a rule, 
it will be advisable to vaccinate the child, unless it exhibit 
evidences of variola. While in mme cases the child ajipears 
to l»e protected by the mother having had sinalliwx during 
pregnancy, there is uu certainty of this protecrtion. 

Varioloid during pregnancy involves only slight danger. 

Cholera. — Liability to tiiis disease the same during preg- 
nancy ns without it. Mortality greater as pregnancy is ad- 
Vttut^l, Al>ortion or premature laljor is frinjueut, and may 
even occur after the woman survives the attack. Many die 
before the womb empties hndf. Mihl cases may recover 
without alHjrtion. The chihl dies from asphyxia, or cholera 




166 INTERCURRENT DISEASES OF PHEONANCT, 



iuftH-tiua, or f'runi ]Miiholugit'ul (■huti^es in tite uteriue mucous 
Tuombruuc, <-horiul villi, uiitl plucunta. The rlinicul Liblory 
i« the same as in cu:?^* without pre^nuucy ; »o is the trtaivmii. 
The iniiiiciion of pretnature labor — formerly reeomiueinled — 
IB uot advisable. If labor occur, judicious meane to ha^teu 
it are lulmiteibie. 

Pneumonia. — Acute pneumonia during pregnancy \a rare. 

When it does occur the duuger to Loth uiolher mid child is 
very jfreat, and increases with tlie advance of pregnancy. 
Duririjf the liii*t three monlht* uUiut lialf the women die ; 
whereitis if the dii*euH* occur duriu^^ the firi-t sii nutntlw only 
one in five or nix dies. AUirlion or ))reiiititure lalwr often 
occur, and more often in proportion hh the pregnancy la ad- 
vanced. They greatly mid to the danger. Li tome cafcea, 
eveu of exteunive pneumonia, the prc^^uancy nuiy coutinue» 
and both mother and chlh) gur\'ive. 

The death of the mother ig usually nwrihed to cardiac 
failure, ^unetimeii associuteil uith hydncniin and pulninnary 
oedema. The child die* fivmi high 1eni|>eralnre, deficient 
oxygeuatiou of the blood, and iuiperlecl l>lood-:jupply to the 
placenta. 

Treaimf^tt — Prevent the ix'currence of abortion or prema- 
ture laUir, if |MiKtiihle. Whcu lalx>r comes on, it should be 
hastened by all pruttent mejiUH, sm in ordinary cafeif) ; in ad- 
vanced pregnancy, by forcepts etc. The general treatment 
must be dire<1ed to strengthening the waning heart, viz.: 
brandy, annnonium carlH>nate, digitulih, and l>eef c»een«% with 
quinine to reduce temperature. 

TuBERCTLAB pHTiiisis. — The ca5»efi in which pregnancy 
»fienui to retard the progrew* of phthi.-ua, or prevent ilH inva- 
sion, are extremely few ; thopc in which it pre<^'ipitatei' the 
disease and hastens its progress to a fatal termination are 
many. The puerperal Htate an<l lactation still further favor 
the development and progress of phthisis in mcwt cases. Abor- 
tion and premature lalxir are not (amnion, unle^^ the woman's 
con<lition !)e extrenie and she is suffering from deficient aera- 
tion of the bltHxl, when premature deliver}' may occur. The 
subjectif of advance*! pbthi^s are not apt to .ictmie pregnant : 
they uBiuilly have omeuorrla^a, as well as leucorrhoea, and 



HEART DISEASE. 



167 



probably do not ovulate. In the earlirr plages of phthUis 
foiKvptioii VA not iut€rfer«t] with. Tbe cliildreii ol' pluhitfica] 
niotliere are usually small iii size, InU do not lurt'iwurily 
preseut any miiuitent evidem-e of deiet-tive devebiprneut : 
they lire predisjxwed U* the diseasi?, a* wtdl a* to tidien-ular 
peritonitiiN mciiiu>(itis, elc. The pluoeuia is liable to l)t.^ ut- 
feeted with craloareous de;;eiienttiuii in lubercuh'us wumtu. 

TretiimeuL — When laUir o«)nh^ on, early assisUince should 
be renderwi by forcepts to i'ore*:tatl any iuereai*e oi* fire^xist- 
ing prostration. The mother sliuiild not Iw iillowe*! to nurse 
the ehihl tor the same re^iMui, ais well u^ tor the addilioiiul one 
that her milk would not l»e projter for it. A wetrourse or 
•rtiKcinl food must b*? olitained for the infant. Woitit-ii pre- 
dis|Ki^d to phthir^u should be advi^eti uot to niarry, as well 
for their own sake aa for that of their pri»peny, who may in- 
herit the i:lisieac$e, and that of their busljuuds, who may cou- 
traet it by iufectioo. 

Heart Dihkase. — The heart during prepnancy undergoes 
n phyaiolojrieal tiH)/utioiit cliiefly rxinsii*lin^ of hypertrophy of 
the left ventricle, thut) euabliug the or;^an to [)erform the 
extra work whieh prefj;naiicy re<juires. At^er labor imythttion 
ooeur^, the orj^an retuniiu^ to the eonditiou in which it waa 
before conception. When to these physiolopcal chaufjes of 
evolution and involution arc n<lded the valvular legions of 
diseiise, it confttitutes a serious and dangerous coniplitratiou. 
Most of such i'Asesi are ihoi*e of chronic valvular diHe4ise re- 
sulting from rheumatic uudoi'arditia. Acute eiidocarditi» may, 
however, set in during prepnauc}*. or an old latent case may 
hecimie acute from the violent strain imposed upon the valves 
durinj; the exertion of lalwr. Acute ]>ericar4litis is extremely 
rare durin>^ pregnancy, and in the few observed easels pr^K" 
nancy was not interferwl with. 

The several results of valvular disease during gestation, 
varying iu ditferent cases, are: dy8jm<ea, pulmonary conges- 
tion, cedema, and hemorrhage; hemorrhage from the nose, 
stomach, and other organs ; general dropsy of the s<*rous 
cavities, with congestion of the liver and kidneys. During 
lal>or, or after it, embolism may occur, the emb<di khlging in 
the brain, liver, or kidneys, with corresjHinding symploms. 
In bad cases abortion or premature labor occurs. 



168 ISTERCVRREST DISEASES OF PREGNASCr. 



Syinpt-iius iiuticatiiig serious emimrrassmeiit of the circu- 
lutiuTi \\o not imimlly be^iii until the lutttT half uf preguunoy 
— al>oiit the liflh mouth ; they increase with the Hilvanee of 
pregnancy, ami bec'ome worst of alt during the exertion of 
parturition. Thus moderate tlvepncea and ]>aIi)ilalion may 
p> on In im|M*n<]tn^ suffocation, cyanosis, feeble and irregular 
pulse, \oi'n\ couj^'ei^tions, and hemorrhages. The fo-tus may 
die from im|iaire<J nutrition, or from deficient oxygenation of 
the mother's ldoo<l. or from the mother having uictrorrhagiji. 

Mitral lesions are worse than aortif ; mitral KteniMsis is more 
grave than mitnd iiisutticiencv. The worst ciuita* of ail are 
those in which mitral and aortic les»ioiis coexist. 

Treahntmi.—Womeu with known valvular diseafie should 
be advised not to nuirry. If fMissing succeatfully through one 
pregnancy, they should l>e advised of the greater dangers of 
a succeeding one. The me*iicinal treatment of the heart 
le«iou is the same as in the non-grnvid state : viz., digitalis, 
strophanthns, stryrhrnii, etc. Kxjywiire to cold and nnisi'uhir 
exertion mnyt be avoided. Should the embarrassmt'iif ol" the 
circulation and rcs|«iratinn threaten tlie woman's life, the induc- 
tion of premature lalwir is justiHuble. Lal>or, whether s|)on- 
taneoiia or induced, should be assisleil by art — forcej* or version, 
cto. — so as to hasten itw ttTniinatituii fln4l IcA'ien muscular eHcirts, 
Ixith uterine and iibdcnninal. on the purl of the woman. 
Moderate nnieslhe**ia, wilh caution, is advisable during deliv- 
ery. TJie liability to aeute inlhimnuUion al>out the valve**, 
in consc'|uenco of labor, ami the p^jssible occurrence of eailjo- 
tism, shoulii enjoin a guarde*l pn)gnosis, even after tlelivery. 

CiRAVty' DisKAHE (ExopiTTHALMic Goitre) may orig- 
inate tiuring pregnaucy and disappear afterward ; but if pre- 
viously existing it is made worse by gestation, with a tendency 
to uterine hemorrhage an<l linhility to fotid dciUh. doiirc 
without exo])hthalnios is als(t increased by pregnancy, and may 
pnwluce sufficient dyspntea to require relief by trai'heotnmy. 
There is no s|»ei'ially clitferent treatment for these diseiu»es than 
that employed in the non-gnivid state. 

JALrsmrE AND AtTTE Yellow Atrophy of the Liver. 
— iTauudice during pregnancy is rare. In itfi simple form, 
under the treatment of calomel, saline laxatives and diuretics, 



• 



ABORTlOy AND PREMATURE LABOR. 



169 



it may <li«ii>|Kiftr without any Virions result to mother or child. 
But every <*tu>e hee*tni<'S ni' ahwtrhinjr interest iimsmuch a» it 
>;mj/ !te tlie Ile^^il1llill^^ or at leu^t the initial inaiiiferitatiuu, of 
that most (lUiil Cnriii itt' iliHt'tise, viz. : arulf i/riltnr ttfroiihjf of the 
litfr. Thin ufunlly bejriiis like eini|jie jiiuiHiiee, foJlowcHl by 
elcvatiou of tem|)trnture, frequeut pulse, lethnrjry, <lelirium, 
various hemorrh»jr«i, petechia, a)uvul8ioii», stupor, coma, and 
death. Abortion or premature lalw>r may occur. The foetus 
and Ii(]uor amnii arc sometinui* .stained with bile pi^rmcnt 
The |)atholopy of tlie <liwtuie i>> un!*eltled, 08 is alRj \{6 cause. 
It hiLs lieen ai4cril»eil to phoHphorus poinouing in some iiiPlances, 
It nmy W'^'iu as early as the third month ; if more likely to 
ap|)enr at the ?ixth or seventh, or may be post|Mmeil till near 
full tenn. There are albuminuria nnd deficient eiiniiualion of 
urea by tlie kidneys, I*re)Lrnancy aud the conditions iA' a first 
pregnancy preilis|>0{* to the disease. It has been nFcribed to 
violent mental emotion. It has appeareil to he endenuc, at- 
tacking a nuud>er of [ire;Lri»iuil women. Treatment is without 
avail. Emptying the uterus does uot save the patient 



CHAPTER X. 



ABORTION AND PREMATURE LABOR. 



BORTION in delivery of the fa'tns brj'oiY it U \iMe — i. <•., 
before tiie end of the twenty-eighth week. Bet^Nccn this 
time aud full term, diwbarge of the ovum is called •'yr^- 
pmUif't' fttbor.'' No other divisiiui of the sulijecl in nece^wiry, 
though amie writers limit the term 'Utitortiov" to discbarge 
of the ovum during the first twelve weeks; if it o<-cur be- 
tween tjje twelfth and twenty-eighth week, they call it *'niiV 
carrittfjry The symptoms, however, differ (tomewhnt during 
the first three mouths from those of the suweeding four, us 
does also the treatment. Exceptionally the cliibi is vialde 
before the twenty-eighth week, even a moutL or two earlier. 
Bucli cases are rare. 



170 



ABonrioy asd phematvue labor. 



FKKgrKNCY. — AlHiut one out of every five* pregnanoiefl 
eiultt in :tlH>rlioii. iiitd ninety |it*r (tnit. til' chiUnti^Anug women 
alK>rt oniv or more •liirinu llieir livti<. 



C'auhks. — Tho prttdls^toKiurf catutfn tuny refer to either 
mother, lather, or chiKI. 

A ileiul t'a^tus bt j^eiierully ex|>eUed without luuoh delay. Its 
death inuy iw ilut' to tli^juH; of thu |»hi4H;utii or iiu'iuhniueii, 
or nhsinirtion in tlit^ uinhilical ajrd. or ext+'rnal injury, or 
dt'Hrient uutritiim iVom ii vitrit'ty of rircunihUini'es, or iu- 
heritiil etyphiliiii, or luiucrul uud nthor [loiHiiiii* deriveil from 
the iniilher, or tron) the eruptive fevern. llitrli t*Mii|»erHture 
on the pari <»f the nmther whui kills thy child. When the 
njoiher's U'm|»enilurc reiirhtsd l(Hi° it i.s iilways fnUil to ihe 
fiBtuM, uiid 11 rij$e to 104*^ is duiiLrerous, the danger l>eing 
greater when the rise is Huddeii inste^id of gra<lual. The teni- 
pemture uf Um Uutiu w a degree hij^her than llmt of the 
mother. 

On the part of the mother, eonstitntional sypliilift is a 
|)Olent CHU:«f- The ocrumnre of aeute iMriamniatioii of tlie 
thoraeie or ahdiniiiuiil vi^'eru : tlie oxanthenintous fevers ; 
plethora: aiiuMnia ; allMiminuria ; i^j-rrtwirt' vomiting; eousti- 
IMition ; plaeenta pnevia ; di^L-uw::* and displacements of the 
uterus, espixMulIy relmllexion and retnjvcrsion ; multiple preg- 
uaney ; ehronie lead-|Mjisoiniig ; elironie er^oti>ra from eatiug 
bread ma*le of Hpurred rye ; the precSM-ioui* or very late 
o<!CHrrence of prejjrnaney ; the " abortion hahit" — this hist, if 
it have any real existetnee, usually means chrouie nietriti**. uter- 
ine displacement, or >»om« other disease which pnxluees recur- 
renre of the abortion. 

On tiie part itf the father, pret'ority, anility, syphilie> de- 
l»ftuehery, and ili*bility may lead to it, 

EscUing i 'liu^A. — Mechauuiti luofnwe, at* blow?. falK violent 
exertion, the eoneussion of railroad accidenlit, execiteive veuery, 
seo-bathin;^, irritiilion of tike inanimip, tot»th-puUing. etc. ; or 
emioiional violence, a^ excewive fear, jny, grief, auxiety, anger, 
eta 

Many altoriionn tio doubt occur from the wilful adminiiitra^ 

1 In r (( ini r . .llriiiDft r.f ttil?t wirk tlif ftciiueiii'v WHii Atuliil irt Ik- tiiif »ml of 
fuv' > K. it It prnl'iiMt' Ou- frc<|iu-iu'y \b atutimuxWy iwrvtuina wuk 

!h' Mt* nf civiUxjitl-tn mi.l lite ilifTtialon of knowicilKC U) tu mctb- 

odft < ' ^ 'itHirlioii iiiiioii); (III- 111 it y. 



DIAGNOSIS. 



171 



tinn of drastic! pinnienagopiiR me<ticine8 and from inteiiHonal 
disturlmiK-e of the ovum with iiislnmifiitjj. 

Tht^ iilHtVi* cnusiw not, tor iht^ iiujMt |>nrt, in one of two ways, 
either by prwlucing daith oj the JitUis or l>y iutiuoiiig uterine 
eontractiun. 

The inu6t dei^ided ejctiiinQ caufies are often Btraiij^ely inert 
in the alB*eiice of any pirdijtjxnaing ones. In p<»nie women 
with an apparenlly " irritable uterus " very slight exeitiug 
cau«e» will bring on uterine ooutraction ; iu others all eorts of 
injurioA and surgical u|X'ratioiia — even eeliotomy, removiil of 
uvariau tumors, removal of fibroid tumors from the uterus 
itrielf, and amputjition ut the hip-joint nuiy sumetimes be doue 
without any di^aurhum^e of the uteruet or ovum. 

Period of C)tX'URRENt:E. — It wcurg most frequently during 

the jset-ond and third moullus though, ((uite |HjN!*ibly, many 
abortions iluriny; the Hrst mouth are never recognized. 

SvMi*T()Ms. — /*at/*, intermittent iu diameter, and due to 
Uterine wmtractions — in reality, miniature lal>or-|iaiiit; ; and 
hemorrhage, due to partial He|)aratiou iii tlie ovuui from the 
uterine wall. 

<'hiliine«e, nervou.sne«», anorexia, t'liuuU flighty pains in the 
back and aUlomen, i're<iuent micturitiou. and a mucou.-* or 
watery discharge, may occur and continue some day;* In-fore 
*' lalKir-paius " and bleetling, but they are not common until 
after the thinl month. 

When the unbroken membranes with their contents are 
expelled entire (like a *'s«>i^-shelle»i egg"), which is mort 
likely to hap|KU during the tirwt three monlhj*. the hemnrrlmge 
may be only moderate ; but when the siu^ burslj^ ami n^liajiees 
after di^chnrge of the ftetuB and liipior anuiii. bleeding is 
usually more prt»fuse. In thea^ latter can's the bleeiling and 
pains may ceasH*. for hours, days, or even wet-ks. Imt if the 
platvnta or mendinme la; retaiutMl, the?* symptoms are >^ttre to 
return 9oouer or later ; and in case the retaine*! secundines 
deeom|Hjee there will be added a pulre»cent odor of the dis- 
charge, and, likely enough, a severe chill, fever, vomiting, gen- 
eral depression, and all the other symptoms of septic inteetion. 

DiAONoeia — PaiuB and blee<ling having otrurred, the diag^ 



172 ABORTIOy AND PREMATURE LABOR. 

'DotiH in reufli^reil pofdlive hy vti|nn&] examination revealing 
partia! \>t n)iii|)K'te dilntnlioti of \\w o^ uteri, au<i prceeutation 
ill it of* tlie \\H)Z or wan*r.s iinihiliciil n»r(l, (tr Uodv (tf the 
ftplurt. Examine ttU tliwliargt**, |»refV'ral)!y umU'r waler, for 
traces of niembraneu, ia'tiis, and i-horial villi, otherwise abor- 
tion may otrur without recognition. 8hould douht ariw from 
diM:harge^ having l)een thrown away, uuexamiuwi, it may lie 
«tate<l as a tjpneml thU tJiat if the wonih have eonipletely 
emptied itself, the symptoms will sul»fiide ; if otherwise, they 
will i-ontinue, or rei:ur at\er a iKjc^^ilile remit^iou. 

DiAQNOPis OF Abortion from RKTrnstNo Menstrua- 
TioN.^ — In nienMruation bleedin^r ^'euerally relieves the pain : 
not so in abortion ; meurftruati(>u oo<Mirs at the period : abor- 
tion not nectttvarily ho. lu abortion there may \w a history 
of violenee or i*ome other cause for the symptoms, and the 
early sipne of i>re|j:Tianey will have appeared. 8houbl di^fital 
examiuatiuu not ittford sufHrient evi<1eLK'e to elenr up doubt, a 
pnttiiirf^ fliajfuosis moy l>e imiH>s>ible until the os uteri liave 
sutlieiently dilaleil to admit the fmL'er-end. or iiutii a part of 
the ovum ha* been expelled and reet)gni/e<i. 

Diagnosis of ImrviTABLE from Preventable Abor- 
tion. — Persistent and profuse hi'iuorrhajre, frequency and 
severity of the pains ; couMderuble ililatatiou of (he os uteri, 
which riipidly progresftes, as a raff, indicate thai the abortion 
cannot l>e prevented ; but exceplions may occur. If the fu?tU8 
be dead, or the menibnines broken, the abortion lje<'omes still 
more inevitable : but it is not ca.«y in all cMfH's to be sure on 
lhei*e two ikuuIj^, and rr/y exceptional cnses iMcur in which a 
deail fa't»is ij^ retniued lor months an<i years. A prepnnncy 
hai" even been known to continue atWr the iiiendirunes have 
been puncture<l, and after pieces of the decidua have been 
discharged, ibllowin^ (he intnxluctinn of the uterine touud. 
M«wt cjiseH follow the ijcnemi rule first alx)ve Pta<e<l. 

D1AONO6I8 of Incompletk Abortion. — In cape* where 

(he (lischnrpes hiive not Iteeu carefully examintvl, or have been 
thn->wn awny without cxaminaliun. and iu which demonstra- 
tion that the entire ovum lins l>een ex|)elled is in this way im- 
possible, the only sure methoiJ of diugnoeis is to jwisb a iiiiger 



DfAGNOSrS OF F<ETAL DEATH. 



173 



into the uterus ami feel whether portions of the placenta and 
menihrnues etill reoiuin. 



DiAoyasis of CoMPtrrrE nrx Covckaled Abortion. — 
ThJ8 is very iliftitMjh. It (It-pentln ohietly u|Hin the hijitury of 
»igii« nii<i i^yniptoiusi imlicatiii^ |irep]ain.*v ami aWrlion ; luu! 
ujxMi the rwo^nilion nf* jin fnlurp'il uterus growing^ t^iiiulItT 
by involution, the lixhiul tlisi-lmrge, and Mmedmes tlie ap- 
pearance of milk in itu* brcii.'?tt=. 

DiA(JX0si8 OF F(ETAi^ Dkath. — The xi*r//M of ffda/ death 
are : lan^fuor, h»w spirits, pullor, ehilliiiet^ |>erhu]M K>me fever, 
sunken eyes surrrjuntle^t hy diirkeneti riuic, naiij^ea, anorexia, 
fetid hrpjiih, and Imd Ui^W- in tl»e mouth ; u leelin^ of weight, 
di«'onifort. and eoldiiess in the hyiMijriUstrium ; riahhiiiww, 
with stationary or diniinislial size ot' abdomen, with bwvs of 
its normal tirmiit^ts and ehwlieity ; thy utvrui? rolling more 
easily from side to side ; fla^.'eidiiy ami diiuiui^hed size of 
hreasL*!. with the apiH'aranee of milk in them. Thf^se sym|»- 
toms may not come on until .'»inuf (i mr afhr i\x.'iii\ death. They 
may al.^o be produced l>y other cnuseH. The octnirrenc* of 
several is ueeessary for dia^rnosis, which lai>t, even then, may 
not l»e positive. Fetid dit^'harj^e** per t^ijiuam^ with or with- 
out exfoliated epidenui?*, are more reliable, llecvntly the 
detection of acetone in the mother'^ urine (a<!etoriun:i) has 
been eon.^idereti an invariable sipi of f<etal death. The nietlKxl 
of dete<*tin^ acetone is iia ftdlows: 

Letjat's Tf-M, — To 5 cubic centimeters of urine, add s<n'eral 
drope of a freshly made strung w)lulion of wMiium nitro-prussitle 
and a few dro|^ of sodium hydmle. A retl rolor a[>j)ears, 
soon rhaii^in^ to yellow. If now a few drojie of strong acetic 
acid be allowed to triekle down the test-tul>e so as to form n 
se|Nirate layer, the yellow color WMtn change** to earniine or |>ur- 
plish red at the line of junction ; and on standing a (greenish 
prussian-blue cf)h>r is developed. 

Le Xohff'n Ttut, — Adii to the urine a solution of Hoditim 
nitro-pruHside. previously nmde alkaline by caustic wnla, and 
BO dilute as to have only a sli^jht red tint; if acetone Ik? 
preeont, a ruby-re«l cnUtr uill l>e pn*duce<i, »<H>n chanjjrin^ to 
yellow^. Then on nddin^ acetic acid and lajilinfr, a greenish 
blue or violet color is developed. 



174 



ABORTION ASD PREMATURE LABOR, 



Finally : while tlw chiM lives the tem|K?rature of the nfenu 
fna tK^le<i l>v a tlieriimnieter in the cervix ) will lie one or two 
We^rees liitrliLT timii lliat of the iiujitin: it* it b« not so, the 
ehild is nn>**t proUnbly Jt-ati. When pre^rtiaiiey has KuHi- 
cieiitly a<ivanre(l. iht* ahwnet; or ees»fyitiim of previounlv rcTog- 
nized heart-swuiiids and t'o^tal movements is important. (For 
signs of fa'tal death during labor, at or near fijll lonn, see 
Chapter XXIl.) 

Pboono8Ih, — AlK)rtiori» often corimime more time than full- 
term lahon*. owing to the luni? and narrow cervix ureri, and, 
as yet, iun)erfeet developinf^iit of the uterine nuiwles. The 
i»ei'undines are often retainetl houn* or days after diK'harge 
of the fo'tufl. With proju^r treatment aUirtion is it(ddoni 
fatal ; it is !e»i dangerous than full-term delivery, aa reganls 
the ehances for life, hut it is far more likely to leave chronic 
uterine di»)eat«e and great debility from hemorrhage. 

The chief dangeru are hemorrhage antl ^ptiofonda from 
retained swundinea 



Treatmknt. — The treatment of nlwrtion will (liflVr nnich 
Beei»rding ai* we dwign to prevent, or, on the otluT hand, 
haftten clelivery. 

[f the hemorrhage l»e only Might in degree, and the ])ains 
feeMe, if the oh uteri lie m)t much dilatetl, and the mem- 
hranes not hriken, we Htrive to naitinue the pregnancy ; if 
opiNmite coiulitioiip prevail, we cannot do w», hut nnisi hiiFleu 
delivery to put the woman in safety. 

Should the fietu? be dewi, the uterus must, of oouree, be 
emjttied. 

Trrnimmt to Prct^mi a Threalened Abortifnt ithen (he Stfmp- 
iom» art' Siifjhf. — Alwolule refit in the re<Mindient pot-ture, in 
a rottl rfK)m, with light be<l-<'lothing. Mental and emotional 
quiet. CVwling drinkp, avoidance of all ptimulantR. Opium 
(preferably the liq. opii sedotivuR, gtt. xx-xxx) to arrest 
uterine contraction and check liemorrhnge ; or a »upp(»«itorv 
of morphia : the opiate to be re|ieale<l every two houn*. or 
as often ns may Ito tiece«iary to ntop the fnuna. Chloral in 
Icn-gniln dofes, or phenacetin five to ten grains*, may be uHe<i 
in the i*nme way. Dr. Flayfair prefers chlonnlyne in len- 
luiuim doses ever>' three or four hourp. Mild laxatives — salinos 



TREATMENT. 



176 



castor oil, or wni|>le eiienmta t»r warm water — tihouKI \te used 
to overt'ome ooiislipatioii prtHliKvd l>v tlit' o|»iali:'s. Never use 
ergot or the tunifioo : aud tlie n|t{)lieutiuLi of ooXd clotbe to 
prevent hcmorrlm^e is of iloulufiil utility : it rather uu^inents 
uterine contruotion. The Viburnum pruuijullum ( Hil. ext. 5j, 
or iH)lirl ext. pr. iv in pill every two or three huurs) i? alleged 
to Ih' a valuiihle preveiuive of alKirlioii ; il (piiets uterine lon- 
Iraetion. Evidence in favor of its utility is inereiiHinp. 

Remove mxy known cjiii.s*^ of the symptoms ; and restore, hy 
poittnre and {lenlle maiiipuhition, any existiiif^ uterine dis- 
plaoenient, esjteeially retroversion or relroflexion. 

Etforts to prevent aU^rtion must, of eourse, cease after the 
ffrluK M ilrntl, but of this hist event there is, during the first 
thn-e months, no unei|uivoenl sipi. Keilurtiun in tlie size of 
the uterus, or il* snmllnt^s wlien eonijjareil y^\v\\ the known 
duration of the prepiancy. is perhai*? of most dia^'noslie value 
in this res|>et!t, (8ee pre<'(Mlin^^ pnK*'-) 

Tiftttmt'iU u'hen ihf Aftortion i> Iiieritabfe. — Let it be pre- 
tnis^Hl that in all manipulations and oj>erative measures — 
whether di^itnl or instrumental — resorted to in abortion cUBes 
llie same riifirl anh'jifptir tfclniitfur must be oliserved as in full- 
term lal)ors or suririntl operations. The external ^renitals 
must l»e made nsepti4*ally rlean Ity (firttt) scruhlfiuj; with hot 
water and soap, and («'*for#W) swabhiu)^ with a I to iit It 10 bichlo- 
ride ot' mereury Sfdution. The vaj:ina to be washed out with 
the same. The hands and nails of the operator to he eleansed 
in a similar manner and rinsed in a 1 to 1000 solution of the 
birhloride. All instruments to he sterilized hy immersion in 
boilinj^ water, or in a o jn^r cent. s<:dution of earholio aeid, or 
ft 2 per pent. Ptdution of creolin. Textural fabrii-s, tised for 
tampons, etc., must be rendered aseptic, either by <iry he«t 
(hakinio:) or by immersion in some pennicide fluid. (For 
further particulars as to antiseptics, see Iii»bor, Chapter XII.) 

In most rases of aitortion delivery may be Iet\ to complete 
itstdf by the natural pt>wers. This is cs[>ecinlly true of caseB 
octrurrin^f duritii; the lirst two months of pn^^nanc-y. Inter- 
ference may Ik* rc<)uired in these, and later <*aw^, on artH>u!it 
of rxrriutivr finnorrhnffe. This may alwa\s 1m» furrfy arretted 
by the vajjinal tamfwm pnnK^rly ap|tlie<l. The iJtm{Kin also 
tdimulatfft uU-ritte cojitntrtiou and promotes complete sepam- 
lion of the ovum from the uterus by cnueing eOuaed blood to 



176 



ABORTION AND PREMATURE LABOR. 



biK'k up and awumulate l>etwten the womb and ftetal mem- 
bniiK-H. The iMmpon \» u vaginal pln^, fx>nBii:tin^, preffrubly, 
of disks i>t' aiili!«eptic <olton, fhee*ie-cIoth, or indittorm gauze. 
Wht'U thttte are iioi af iiand, in ca«« of emerjrpiu'V, pie<x¥ of 
old mheetiii*. or ot a w)tl lowtd, or an unrolle^l roller Uuidajce 
may l>e uat'd. They should first l»e pouknl in a 1 to 'JOOO 
solution of bithloriile of mercury, and wrung out ; or in a 
weak Holution of carlHilic acid or creoliu. To facilitjite easy 
withdrawal of ibe tampon whiui it cout*it^tt? of i^ejHirate pieces, 
these may 1k^ cotnu'dHl I»y a striniir, like the bitji of pa])er oti 
a kite-tail ; but it is eiL'iit:!r to um* one long narrow strip of 
material. 

Before introdunnj? it, empty the l)laddcr, WHi»h out the 
vtijrinft with tho bichloride solution, and apply the tampon 
lhroii;jrh a s|X'(iiluni (preferably Sims') with a long \mr of 
ordinary drcsfin^r forceps. I^t the iirsl piet^etf be |>acked 
l>ehiad, and then others all around the cervix uteri, and so 
contitiue uiilil tlie vnjrinu be cumph1cl\j and romfMiftlij filled, 
withdrawing iht^ s|)e''uluru by deirret»f as ibe [lackJnj; proceeda 
al»ove it. To prevent the vajrina ex|K'llin;r ihc pln>r, place an 
iintifiridic ])ad iiver thi> vulva, wH'ured by a T ban<iage. 

When no spitidum is at hand, pans two tin^fers into the 
vagina, llniH S4^pani(in^ the bibiii, and push np llie piece** of 
cotton bHwi'Cii lliem with the drer^sin^' force(«, each piece 
bcin^ anointed with carlxdized oil or glycerin to prevent fric- 
tion and chatuig of the vulva. Be careful to avoid turning 
in aiiy hair. 

The pluj; must not remain in the vajrina lonjjer than twelve 
hours — Itetter not more than mx or ei^dil. If thv woman be 
very weak from hemorrhajre, a seromi om^ shonld U' in readi- 
ness l>efore the oM plu^r is removed. The bladder must nfjain 
be emptied by the catheter if re<pjired, and the vagina cleanii>ed 
with carbolized water. It is not alway.s neceKwary to repeat 
the Uiuijwni. If aller several hours the pains cease and the 
woman l)ec(»ne eai*y, the ovum will pnjlmbly be found in the 
vagina (when the pluff is removed), from which it may be 
eaaily extnictptl. and if entire, with cessation of bleeding. 
Nothing further will l»e m»ede<l tlmn deansiiiK the vnpna with 
an antiseptic solution. However tifrbtly the lani|M)n may be 
put in, there will always be nH)m alcove it for the uterus to 
extrude itA contents. Should the hemorrhage continue, and 



TREATMENT, 



177 



le ovum still remnin in iitrm, repeat tlie tampon, and pive 
[^ergot (tl«J. ex(. 3RM every three hours). We may be able to 
expedite delivery hy ciirftul nmiiipulation, when the os is 
dtlnted atui tlie uvuiii |irfitriHlin^' thnni^h it, hut if (lie mem- 
l^ranesi l»e still inturt ue IkhI InHtfT ul)!*l:ui» ihnn this otiort lest 
w«» rupture them. The n^petitioti of the tiiHi[Mm fhoulil not 
be coutiDUe<l longer tliaii tWfiity-lour hours. Atler thin time 
it will \wi belter tt> adopt the more radieal mejipuroii of extraxs 
tion by Hii{j;er or eurette meiUioi>ed further on. 

It i(*very tximnioii after the tinrd moritii. Ies8 fo l>efoTe then, 
for the fa*tu8 to l}e ex|>elled, leaving the memhrnnes (and pla- 
ccDla, if it Ik? deveIo()eil) in ntrro. When this occurs duriug 
the tirst three months, the eonl must be cut vr i)rokeu (iiu 
ligature is ne<*e!*sary ), the f<vtu» removed, and the case trenttrd 
by L-ri^ut aud the tanip4m, as before descrilied. Durinp and 
after the fourth month the tam[Km Is not advisable^ for the 
uterine eavity is tlien large enouj^h to enntaiu eonsiderahle 
bluod, and the utt>ru^< is uIhu futficiently large tu lie Hubjccied 
let compnwyion aud gnijfpiug of its wall with the haud through 
the alMlomen. by which dischurj^ of its eontenti*, contraelion, 
and arresft of hemorrba^ may be effected, or tun) or three 
fingers may be y)a(*^ed into the uterus Tthe cer%'ix l>einp suffi- 
cieutly oy>en) and the placenta detivebed aud withdrawn. 

80 long 111* liny part of the set^undines is reluine*!, even 
ihough the hleetling temponirily cea^, aud whether it lie 
before or after tl»e tliird mouth, there is always risk of the 
bliKMl-How re<'urring, as well ns of aeplinemia (from ilecom- 
popitiou of the retaineil matters I. pelvic peritonitis, and cellu- 
litis. Henoe it is safer in nnv cast* to secure delis'ory of the 
se«'undine« without ilelay. In ca.-H?s where the placenta is not 
a<lherent, but simpiv lodtjed in tftf <vrri>. it amy l>e ho«iked 
down and dit'lodged with the tinger. When it is retuiued 
higiier up in the ut*'rine cavity, a linger or blunt curette may 
lie pasFed to the fundnn ( providt^l the w be sutticicnlly [Hitu- 
h»us, and if not it should l>c ditatc<i with the steel dilator), by 
which the entire retaiiie*! cimtenls may be effectually and 
etmipletely remove<l. In using the finger, it should be passed 
into the womb along one side, then sweep acrow the fundus, 
and fiown along the other side. No man's linger is long 
enough to do this, unless the uterus be fprrfi*al liovti /«/ the 
other liand uptm the abdomen. 8ho\d(l this pressure Ih« paia- 
13 



178 




AUORTION A^'D PREMATURE LABOR 



ful, ether may l>e jriveii for ana-stlicsin ; and, if prcsHure from 
above he tlien luit j*urticieut the woml) may be pulled and held 
d*twn by a viilsellum fon'ejw in iht^ aiiUrior lip. IMai'ing the 
woinau iu the lithotomy position greatly tacilitatee the pro- 
ceetling. 

In any protracted case, the viigiim shouUi be freely washed 
out at least twice daily with soine antiseptic judution ; and 
when the finger or iiiblrumenis have bwn placed in I he iilrnis, 
it t«K> t;hould receive a similar injt*<'tion, aire b*iiiff taken that 
the fluid iimnffliiiteltf ami frtrhf riUtmti from the uteriue earify 
Ity noting that the ns is sufficienlly ujtfn ior this pur|Mise. Hot 
water, as hot an f.-iin be borne, injected for fifteen niinute^J con- 
tinuously into the vagimi and a^'^ainst the cervix, will often 
arrest the hemorrhage teni|M)rarily, and is a good preliminary 
to the iiitro<iucti(m of a vagin:il litnipon. 

The at\er-trcatmcnl of abortion must be continued rest, as 
after a full -term lab<ir. 

In women who have aborted once or more, and who are 
therefore likely to rein-at the pntcei^s, wc f^honld enjoin absti- 
nence from roiUi^ for a year or nmre ; renioval of all suepccled 
ca\ii*t?s of the awident ; when pregnancy again occurs, insist on 
]>erfect rent in bni for u week or ten days iit times corres(K)nd- 
inp to the menstrual epoch. After conceptiou, ctfUvs must l>e 
forimlden during gestation. 

Iviperfert Aboriiou, — Wlieu remuautB of the ovum remain 
in titero, a? they may do for days, week**, or even months, after 
a supiM)s<Hl (vniplete emptying of the wond>. it is tennetl '* im- 
perfect" or '* ine<miplete " abortion. 

All symptoms may subside, wholly or iu jwirt, but sooner 
or later hemorrhage will re* iir. with diwharge of decidual or 
placental dcbrl«, which may or may not be |)Uirescent — in the 
former case endangering septiciemia, etc. Such case's result 
from, and also lead to, endometritis. Ketnined blood may 
deposit 8uccej*ive layens of fibriue n[>ou fntgnients of mem- 
brane or placenta, conslituting SHwalled ''Hbrinons polypus." 
Renewal of pains and bleeding ultinialely result. 

Trentmei^i consists in comjdetely emptying the uterus with 
the linger or curette, and the use of antiseptic inje<'tions. 

MiMntd Abotiion, — As. at full term, the child may die and 
remain i» »trrn weeks or inorilliH afterwanl, coiiPtitniing so- 
calle<l ** missed labor," so, daring the earlier moulhs of preg- 



TREATMENT, 



179 



nancy, death of the fcotus nmy oocwt and the ovum still 
reuiuiii ww-'ki* or muutlm in the uterine cavity ; tiiit* i» ^'miased 

In tlji-Jiic^ WLst'ri tlit^ hiyniptoins of jire^nancy art! Hrrcstrd ; 
milk iu;iy appear in the )»reiiMt^ ; the ti(|U<»r ainnii is a]»<4>rlH<I ; 
tim cliild nmreriit<'ti or iKH-^jmei* " niunmiified " — nillcd up in 
the j^ttCHiita or nit'iuliniiies« tike a ]>an'el — hut usually it is not 
putrid, lor llie unhrokeu mend)mne« liave protected it from 
atniosjiherif f^emis. 

Paiit-*, bletnliu^r, and iinexpe^'t^.Hl discharj^ f»f the masa 
usually rt«ulL When this hk*t does not o<Tur in suajpetied 
canes ( />oj*/(i*r dia^cnosis u* difficult), catlieterism of the uterus, 
or dilatation of itn cervix by tentrf, t<> provoke contraction 
and expulsitHi of the uvuni, is the jirojier treatment ; or the 
cervix may l>e rapidly dilated with the steel dilators, and the 
conteuta of the uterus removed hy the finger or curette, as in 
other cases. 

Before po»filu<linj^ this ehaptxT on alwrtion it may l)e well 
to remind the reatler that with regard to (he trrnttnmt of those 
BCS that do not terminate 9j>oiitaneoualy, and which require 
interference either from exci-sriivo and matinued hemurrhajje, 
or on account of retention of the fifivnuliiies, two vietlitnis of 
practice have grown up, viz. : Jird^ the ej'petimU method, com- 
prisins; the tise of the (arn|Kin, er^ot, gentle expression, or 
digital extraction of the p1a<'enta whert it presents in the os 
uteri, resLTving llie more radical metli(-»d i>t' scraping otit the 
uterine cavity for cases in which deeom|w»?ition of the secun- 
dines is lieginniug. or in which fre(|uently recurring or loug- 
continntti hemorrhage has rendered more octive measures 
rJieoeasary ; Afirond, the mdi'-nl ov active methi>d, hy which nil 
cases consideretl beyond prevention are treated a<'tively /rom 
the hfijinniiuj, the w(»man l>eing ana-slhetized, the os and 
cervix uteri rapidly dilated with steel instruments, and the 
curette useil to empty the uterus — scraping out fietus, |da- 
<*enta, and the entire dfN'idua hy one mmplete o|K'ration — Just 
as H polypus i»r other morhid m'0|>liism wotild Iki remove<l hy 
a somewhat similar surgical pnxreedieig. Jhith methods of 
Irtnttment liavt* their res(>ective advantages an<i i lisjid van- 
tages ; hoth have earnest ndviK-ates ; neither plan has l>eea 
universally adopted. There will probably always bo cjisei), 
or at least circumstances, in and under which each of the two 



180 



EXTRA^UTERISE PREGSASCY, ETC, 



mefhrxlK may Ire judiciouFly employed. Much will depend 
u[M>ii the fX[KTi(?ii<v ami skill of the physimu. 11* \\c were 
ul WHYS a skilful oi>ertiltir ihe rmiirul nu'lliod would rlouhtiees 
be adviwiMe in more ciitk'^ than it ij» nt prt:*!ent, wiieu some are 
unable aud unprepared to undertake a eureliing o]»eratiou. 

Treatmknt or pREMATi'Rt: Laror. — The mannpemeut of 
labor atlertbeeeventh munth i8 about the Biuue a8 at full term. 
r>ilatution uf the 06 nmy be slow, but the child \& smaller. 
The plae«nta iH liable to l>e retained, but not so long as iu 
nlxirtion ca*^es. \U delivery' may be ex|K-dited by compre^ 
pion of the uteriiB thron^'h the alwlonien, or, if this fail, and 
the occurrence of heniorrlm;jre uecertnitjile interlerence, two or 
more fiiij^ern, or the half hand or whole hand (according: to 
the degree of dihitulion of tJie o« uteri, aiirl the i^riotl to 
which pn^^nancy liu** advanced), may l*e inirtMluced into llie 
womb aud the pluceutu (jceled uti' with thu tiugcr» oud 
extracted. 



CHAPTER XI 



EXTRA-CTERIXE PREGNANCY, ETC. 

EXTRA-fTERINE G^»TATION f ExTRA-rTERfNE FOCTA- 
TION ; EXTRA-I'TERINE PRE<;NAN('V ; ImTOIMC (tlitTATION ). 

Development of the ovum outside the uterine c^ivity. Since 
some aise:a, while mitt/thrfti, nro not entirely outside of the 
uterttts the terra *^ ectopic" itt perhu|it* best. 

VARii*mi>. — The ovum may KhIj^c in the Fallopian tulie 
(inhal prerjnnurrj) \ when lodged in that portion of the lul>e 
which panses through the uterine wall, it is cidh-d *' infrntfUial 
prefpifturyy I<;irely the ttd>e is conjrenitally deformed; it 
enl<^rs the uterus externally as uHunl, hut then detwenda in the 
muscular wall and o|ienfl into the uterine travity h»wer down. 
An ovum lodxrerl in such a tulH" woidd «>n8titute a veritable 
*^ hitenUifiiil jrrrijnaurif" The ovum uuiy remain iu the ovary 
afU'r the Uraafiau ves^icle haa ruptured {fnyirwn j/rff^mncy); 
or it may find iU way tutu the cavity uf the abdomiual peri' 



J 



PROOSOSfS OF TUBAL CASES. 



191 



(oneum (ahtlominai f/rfffiianey). There are several sub-vari^ 
tii^ nicntioue<l I'lirthiT on. 

All fornis uf the trouble are rare: extra-ut^iriiie cases only 
occur once in 500 or 1000 ]jrejtcnaueies. The tnhal variety is 
far mure cumnion than nuy other ttnd will lie first conittfjeretl. 

Tdbal Precixancv. < 'ausem. — Spasm. parai3rms, stricture, 
«»cctilat**ti (iilatation, <!ouljlin)jr of, or |)re«»un' upon the ti:lw, 
CAUsiof; ohstnirtion of its (mnal. Ijohh of nliate<] epithelium 
from intiammatiun, hence the ovum does not so easily rern^h 




Pregnmocy In tbe external ihlrd of the left tube. (From P^xvim, after Wincxel.) 
fL Ovary. 6. Left tube. e. Tubal gestation cyat. d. Adhesion. 



the uterus. The lube may be compressed by tumor* outride 
of i(, or drawn out (»f pliKt*. l»ent, arid fixed at an anple by 
conirarlin^ udhef*ionP, the result of |ieritoiutis. It may be 
obstructed I»y small |»<»lypi. In twin cases, each ovnm may 
interfere with the put^sajre of the othor thnuijrh the tulie, 
hence twin.s are nlativfly more frequent in tufml pre^naucirs 
than in normal ones. Friyht during coition is an nllejjtHi 
but doubtful cause. Tubal pregnancy i>* more apt to occur 
at\er than l>efore thirty yearft of lige, and ah^ after prolonged 
sterility. 

pROtiNoeis OF TriiAL Caheb. — All forms of extra-uterine 




182 



EXTRA-UTERINE PRKGNASC7, ETC. 



preguancy are extremely tiaingerousi. The tubnl variety is the 
mot-t faUiI of auy ; if let atone, more than twoih'inls of the 
oiiJH'.s die. By projH*r trealnicut nmny ar<' sxived. The fatal 
resulUs are exphiineil i\a follo\v.s : A:s the fivtjni irruws, that )>art 
of the tuiie in which it w pluewl gruwH wjlh it and hen^mes 
(iistended into a sac or L-yat — really a niiuiuture ulenii'. Van- 
ally williiu the lirst three or four iiumlhs the grt>wth of the 
ovum hursts the cyst, the wall of the latter rujtfuren, and from 
itjs hU'edinj; ve*fi*eli» there txTuru a rapidly fatJil hemorrhage 
into tlie ah(h}ntinal cavity ; ttornetinics death from colhi|)se 
within an hour. Kxcepdomilly the hemorrhaj^e la mtl fatal ; 
then foHows |>eritoiiiti:^ (and tl:^ dangers) |ir»Kliiced by tlie 
presence of hloo<l. tanns, litpior amnii, etc.. in the periumeum. 
Sliould death ftill not wcur, the iletus may hec<>nie re-eneysted 
by a wall of (>rganiz<'d iidhiinmalory lymph, and the wie or 
cyst thui* newly ibrme<l, at a later date inHames suppurates, 
and eventually diiM.'harges, like any other al»sccss, into some 
ueighl>oriug cavity. Death from tteptic^ernuL or exhaustion 
may reisulu Finally, the re-encysted ovum mity remain, with- 
out any inflammation, l>eoome |Mirtiiilly ah}*<»rbed. lenving a 
calcareous, inorganic re-muunl (siM-ulled ]illiop:edi(>n : 8titne- 
child), which may give no further trouble durir»g a long life. 
This is very rare, and should never l>e aQtici(uited. 

HvMiToMs AM) DiAtixrwia OF TiriUK Fkw;nax<y. — This 
abnormal condition is most of\en not sus|>ect<Ml l>efore symp- 
toni:i of a)>prt>aching rupture l>egin ; sometimes not until actual 
rupture hazf taken place. 

The Hijmptomit preiYfling i^iphire are extremely imiHirtant, 
but the diagnosis is ditlicult. The e4irly tfigns of pregnancy 
exint The meust« are aWnt, but reappear irreffu/arhf after 
one or tivo intmth^, leading the woman to doubt her su[)|K«*ed 
j)regimncy. The clischarge is mingled with i*hred.^ of broken- 
down nierine th'cidua. The wondi i** somewhat enlarged, but 
uot as much as it should l»e in a normal pregnancy of the 
ime duration. A tender and painful tumor (the tubal cyst) 

discovered on the side of the uterus, in the vicinty of one 
of the broa<l ligaments. It growH rapidly ; the womb dtjes not. 
The tumor may be deteote<l by the bimanual examiuatiou ; it 
is somewhat soil and doughy, or fluctuating and extremely 
.eensitive. 



SYMPTOMS OF RUPTURE, 



183 



Bliould the vaj/inal iin;;er rec-ojrnisw- iKilhttWment, the <Uttp- 
inwis is «t»rtain. ( >wiiijLi; to pressure n|Kiii the bowel there miiy 
he rrrttii U-firr^mnn in ailiiition U> eoiirfipution. I'rcsjsure u|K)h 
veawls and nerves eiiuse?* aHlemii ami jmin in iltr iiuth of the 
aire4-te(l sitle ; ihetKs ureur ejirlier ami are more eevere than iu 
normal ^es'tutiun, ami may lie luromiianied with slij^lit eleva- 
tion of temi^eralure. The wtmib may Iw put^heil on one f^ide 
by the growing ovum. Eveutually a severe^ learin;;, onlioky, 
iuteruiitteut pain oeeurH in the region of the luiuur, product^l 




PivgnBTJcy in right lube. Pftrtliilly liilm lltfameiilouB ifrtuu Pauvin, after 
ZwRirKL). rt. RIglit lut>c. ft, Ov«ry- <■ ^KwUliMti oynt »ilh f-ilu*. 

hy oonlTnctions of the wall of the tuhiil cyst ; the ** miniature 
Fallopian uterus" \& irrilAte*! to contract by ditntention ; it is 
hnvin^^ "pains;" but since there ia no outlet for ita contents, 
it burst& 

SvMiTiiMS OK RriTiKK- — J^vere nnd sudden alwlominal 
pain, with intense eoUajK^e. pallor, feeble and frt^^pient pulw, 
etc Rapid swelling of the altdomen, h)W down, and at first 
OD the side occupied by tlie tumor ; later, all over. The 
BwelHog is soft aud doughy ; it is produc«til by bloud effused 




ia4 EXTIiA-VTERINE PREGNANCY, ETC. 

the peritoneum. Syuci>pe, nausea and retchiug, cold 
reatft, etc, pret'ede the faUiI eveiit. 

Treatmevt of Tubal Cases befobe Ritture. — When 

Burjirinil Hkill Ih iiviiiluhle the projKir treatment i» celiotomy. 
A^&r thorough cleuDsing and sterilization of the ahdonien and 
puht«» as well og of the iastrunienti* and hands of the operator 
and n»»iiitAnt^ tlie bludder U emptied and the patient anas- 
theti/^l. An incision three inche^i lon^ ia then niaile in the 
HKnlian line nlMive the pulies down to the peritoneum, any 
blt^lin^ ve.ssels beinj; twisletl l>efore o|»ening the peritoneal 
cavity. The {)eritoneuni it- tlien incit^e^l ; the intet«tine kept 
baok by pads of cotton or pauze wrunp out of the Fterilized 
water; the operator's finjrers hring out the dlHtendcd tuiie and 
ovary at the incision atWr having free<i them fnun any exist- 
ing adbcKJons ; the pe<licle is then traiit^HxfHl by a double liga- 
ture of i»terilized silk, and each half of it tied KHnn^ely accord- 
ing to surgical rule. The [>edicle is cut, and the eulire mass 
— lube, IVetal cyst, an*! ovary — reiiiovetK The jmds are then 
withdrawn and the abdominal incision closed uiid dresse<l in 
the usual manner. In rase of tlireatene*] coUajise from hfoior- 
rhiige during the oi)eratiou, the ])eritoueal cavity may be 
flooded with a 1 per cent, uterilized solution of eonnnon salt nt 
a lem|«*niture of 1 10'' F.. a »]uart of this solution having been 
previously prepare*!. It is rapidly abBorl>e<l by the peritoneum, 
and acts as a restorative — like transfusion. 

The <levioe of IdUing the fietuA to slop its growth, and thus 
forestall further distention and my^turc of the cyst — by the 
various inetlKMls of (1 ) aitpiratiori of llie liquor aninii ; (2) 
injection of morphia, etc., iuio the amniotic »iiv ; and i'A) by 
electricity — has, for gotnl renf^itns, bt^'u abandont*<l. The first 
two nu'lhiHls are no longer thought of That nf dc.4tro>'ing 
tJie life of the ftetus by electricity, while inadviwible, might 
still be worthy of consideralion when surgical skill was unob- 
laiuablc or the patient and her friends refused surgical inter- 
ference. The method of pnK-<Hlure is as follows: A faradic 
current is passed through the cyst in a series of sharp shiicks, 
and repeated every day till diminution in the size of the tumor 
ai»d retrffgrade changes in the breasts indicate ftrtal ilcath. 
Oiie [Mjleitlm negative ) is imseed into the rectum or vagina 
and placed in contact with the tumor, while the positive ]ioIe 



TREATMEST AFTER RUPTURE. 



185 



^ applied on the al*iluinpn. Eleotririly sliouUl not l»e used 
when there are sijrrLS imliwiliug iinj^t^mlin^ niiituro; it would 
liasU<i) thnt uuhititpy evunt 

TUKATMENT AFTEK RlTPTURE. — CujliotwIUV IS here UDqUffl- 
tionablv the lx*Ht niethcHl U> purs*ue. The alitloniiiiiil ciivity 
should he ojii^nwl Uy inci^^ion, the Falhtpiiui tulw, with the 
cyst, ftttuii, ovary, anJ eH'uj**.Ml l»li>ij(l, rmiovod, in the tuanuer 
just previously ilescHlywl for casein hrj'orr ru|>tiire., exira rare 
t»ttiiij; takt^u, in tlu» ruptunvl rai*tv, U? quivkhj secure tfie l»loe«i- 
injjf veiiiftels of the. ruptureil lube from further hemorrhage. 
The sterilized salt ^-olution nuiy he uise*! to re<ni|)errtte the pa- 
tient from collapse, as in i-ajies operaU^I upttn heibre rufilure ju>4 
previously des<Til>ed ; the oj^oratiou to lie |wri*orrticd with the 
fitrietest antiseptic preeautions. In forty-two o|j*'ratiou» |>er- 
fbrmed iminf'fll/ttrhfa.iter ruptuni liy Mr. Ijiwsitn Tnit, thirty-nine 
wonieu were saved. Prof. Hirst, of Philailelphia, had twenty- 
four coasceulive oases wiihout a death lh;U loiild l»e awrihed 
t4) the operation itself. He advist^, after liie tulK;. iivary, an<l 
cyst are removed, that the abdouK-u should be (lushed with 
large quautities of hot sEerile wat<^r and drained with both a 
gla» tid>e aiul jjauze (liu-kinj^, Imth of whirth are removeil after 
4H hours, a ruhl>er tulw havinij first l>eeu ]>a«*ed ihroujrh 
the iflasa one to take its pla<N\ For about, ton days the nlv 
dominal (uivity receives, throu^jh thi.s riil>l>er tulw, a daily irri- 
pitioii with hot f»terile water, until it ivimes awav olenr from 
any Hakes of blooii-clot or dei-idual ilebris. Hit* juiticntf> had 
no fever, and "every wound healed pnmiptly witliin three 
weeks," without any |>ersisteut sinus. Ijick of snrirical ad- 
dress, daring, and skill, the want of !«ur(ncal instrnmentii and 
antiseptic appliances, and the dread of o|>eratinif u]xin women 
alnio!<t at the door of deiith will douhttess continue, i\f in the 
'|mst, to prevent the iK-rfonnanee of thin o|M*ration in many 
i»i^ where it ouijht to lie done. In H«>me easei*. aUer o[HMiin^ 
the alniondnal ejivily. the foMal ryst may be fuuntl s<j (irmly 
and exleUKivcly adherenl to adjoininir vijicera and other tissues 
as lo render its removal exlremrly dittirnit and danperous or 
evea inijioflBihlo. EnucK^tion of the sac nhould here not b« 
attenipl4i|. In some of tht^se cjises it may l»e jilitchi><l to the 
&lH](munul wound, em]>tipd of its contetit>», wafihod out with a 
weak bichloride Solution ( 1 : 20,000 ), and [lacked wtdi iudo- 



186 



EXTRA-VTEiaSK PREGSASCW ETC. 



lorin ^uii 



u\ In utiior au*c'*t where tlie siic 'i» low iii the iwlvis 



anil fjLsily rciK'luMl tlironirh tbn vafrinu it nuiy lMM)|N'iit»(i lliroiiirh 
limt canal, rlt^ured of iln ctHiU'iitf, wa«ilK*(l tml, iiiit] (nirkeil witli 
^UUM', Icnvin^ a irri' o|M*iiinL^ tor tlraiiia^'i*. l!i iloini; liolli 
an alHlotniiinl uinl va;.'iual ojH^nUion on thi^ Kitiie ona^iou tlu; 
haiui-s t)i' tlu' o|H'raror nitisl, of rmirsc, never paew iVtjni the 
Ya).Miia tu the iilMloitiiual wonml without thorough diesiufectiou. 
It would he \)0t^t to have the alKhuuijial uiriHiou clojieil hy the 
iiui'oiitiiiniiiated huiidii of an ntsistanL Hhouhl nu uperutiou 
Iw atteinpte<i, tlie only reniainiujr trejitnient it* that of exi>e*-*t- 
lUK'V — a forlorn hope. The woman must l>e kept ai>s<>lutely 
at rest; opium given to relieve pain; stimuhiiits to prevent 
cr>lln[>se ; with ice to tlie alxlomeu ami nMnpn-Hf^ion of the aorta 
to eoulnd lieniorrha^re. There is a bare ehance (he lihiedinj; 
may ytop ami ihe fetiij* l>e('ome re-encynteil hy a wall of infliim- 
niulory exudation, and so remain hannleHh.' or Im* dL<<'har^'eil 
later hy ahsctijtf and burstinjt; of the cy.st^ either externally or 
into some nei^'hlMiring viscus. as already expluiiu*d, 

Intea-ligam!:ntou8 Preosancy (Extra-peritonkai^ 

8i:B-l*KUIT<)NKO-HKLVir, SlMi-PL;Krn)NK(>-AHlM)MISAL;. Thifi 

ifl a variety "f lu?inl prcirnamy in whirh tin- (uU' rupture* 
lH'twe<'n llic; layers of tin- hroad ligament — hetwtvn two fjirr- 
vm^Mirfiut* of |)eritnneal layers, not into the [leritimejil ea\'ity. 
The eH'usion of hlmid is restricteil by these layt-rs of hn>ad 
ligament uimI llie eoniioetive tissue uniting tht-ir upiHwe^t »ur- 
faeuH. Heiieo the hemorrhaire is less likely to he rapidly 
fatal, roristitutiuLr a limited lia'niiito<*ele. wliieh may luH-ome 
ahsorJHrd, leaving' n lithopn-ilion, or d<;veh.i|» into an al>s4'e*is 
later on. The newly iJtniicd ha"iualoeekvm«v. Imwrvcr. undergo 
u wroiifhrtf rupture lhruu;:Ii the distended broad lii^aiufut and 
into the piritoiu-al eaviiy. 

The tiiii<itiiifi,t of intra-lijjjamentDtis cases depends ehiefly ujhju 
the oillniif^r tVtun he?uorrlia;!:e \mu^ /^^x itevrrf, and u|Mm the 
rec'ojruiiioii ol' a m//i(//v j'ormtui Ijut still cin'U]nscril)e<l inmor 
iude|>endent of the uterus, iu whieh may l>e felt flucluatiou 
uud |H-rlia|»H pulsating; vei^ds. This tumor is formed hy clots 
of rH'use<l l>Jood circumsctibcil between the fnldu of broad 
ligament, quite ditfercut from the dou^rhy enlargement dif- 

' Viirhowavttuliir t'ntliolo}r>-. p A£'>^ foumi tlie mtiwtrt af the fiptiis perfectly 
iDtatt onor reiuiiliilU}: thirty ycun in the* l>tM]y uf Us hiatliur. 



* 



t 

i 



ISTKRSTJTfAL PREONASCY. 



187 



fusffl over tite wliole nlxloineii wlieu Jieiuorrhap^e has taken 
[liwt' inside the ixritoneul envity. Moreover, ret-ta! exiimi- 
iiatiou shows Douj^Ias* cuf-de-mc to Ue ftuf/hj^ wliile in the 
intra-f)erit<)!ieal cuiH^ it \a JifM with ettniie<l 1>I<hm1. 

Trvatmrut, — Surjpcjil interference nut iiuineiHately ne<*eS8ary. 
By rest iin<l rt'<uinilM'tu*y, with trentnieiit for the aiurniia fol- 
lowin^r the iiiulerate heuKirrluxL^e, the eti'ueed Mood may he 
nlisMtrhtni, an<I the uoniun recover. loiter on sii|tptjralu)u may 
ooeur, with hymjitouit^ oi't*ej»iiy, — ehilLs lever, rapiil juise, vtun- 
itinjtj. etc, — when ahdoniiiml «-etion will \te re<|nir(Ht. It itf in 
these hroiul-liguuient cascri that ei»tire renioval «it' ihc eyst will 
otleu t>e ditiicult and dan'^eroiii^. and when it will he hetler to 
0}»en the Hae and stitch it to the alKlorninal wound, nn just pre^ 
vioui>ly explained. 

Interstitial Pregnancy (Tubo-i;terine). — ^The ovum 

is in that part of the tnhe passing through the uterine wall. 
Extremely rare. Kiipttire may (wenr inii» the |ierilnneum ; 
or that i^nriiitv of the hi'ial cyst toward the interior ol' the 
wonih may rupture and the la-tus ei*<.'ape into the uterine 
eavitj', and eonie out by the natural jwusape. It ip lens fatal 
than tulml pregnancy, and may rarely ailvance to full term. 
DiffiTentia! <litnjii4nt{fi from other varielicj* very uneertniii. The 
wondj is irrejrularly enlarged, and to a greater dt^fprf than 
in the f)lher vurietie« ; the tumor moves with the uterus; the 
uteriue ciivity is etnpty. lVi>*ih]y the finger in uttnt may ree- 
ogni7x> the bulging wall of the helnl eynt and its contents. Al>- 
dominal MM'tiun may l>e retjuired before the diagnoi^iit can 
be made positive, 

Trt^ttnntt. — ^^'hen the fa*lal eysl bulge's in t<iward the 
uterine eavity« the cervix uteri nniy be dilated, the eysl iu- 
cijie<l, and its contents evaouatefl through the vagina, the fat? 
iKMUg arterward cleanse*! antiw»])tical!y and packe<I with iodo- 
fi>nn gauze. When the cyst bidget* the <itl)er way, toward 
the out^>iide of the uterus, an abdonunal section bhould he 
made ; the cyst o]»eoed and emptied ; the edges of tht* opeidug 
lUtured to the wall of the alwlomen ; the bleeMling vessels 

rured ami the sac draine<l through the alxh^minnl incision. 
8houhl this lie found impracticable, the oi>eiiing made in the 
periUiueal surfa^v of the cyst may Ik? securely stitched up (ns 
in ftu ordinary Ca-mtrian Section operation), a couulerH>{>ening 



188 



KXTBA'UTERISE PllEO NANCY, ETC. 



having been previously made, for drainage, from the ravity 
of the cyiit into the aivity of tlte utertu;, the alHJounnttl iu- 
vision Ijt'iuj; then ciuswi without druinii^t'. The cervix uteri 
flbouldt of cuurne, huve been thorouglily dilated iMfforehand. 



Fio. 73. 




lntenitiUAlortubo-ut«rineprcgnuicy. (From I*i.aypa[II, after Blami> Suttom.) 

Another devi<x» is Porro's operation : take out the entire 
uleruHwith its iinitent.s by t^npru-vnginat amputation, through 
the aUdoijiiiial route. 



Ovarian pRWiSAXcy. — Its ooeurreiiw has l>een disputed, 
l)Ut a tew rases have undonhiedly Iteen ohservwl. The ovisac 
((.iraatiau voeiclej ruptures without tht* ovule t^'aping ; 6i)erma- 
tozoa enter through the rent, hence impregnation and gejsta- 
Uou begin in tlic ovary. Tlic wall o{ the ovisac and stroma 



ABDOMINAL PREGNANCY. 



189 



of the ova rv filiate to form (lie fu'tal cvKt ; Init gradual rlis- 
tentioii rimy force the ovum piirliully out of ihe ovftrv aiifl 
into the [»eritnneiim. the |MirUoii ejn'npin^ \w'\w^ eireiini«eril»e(i 
l»y iieriioiienl lulheniorii^. Ktijttijre tiffuaily oeeiir? within three 
or iimr luonths with the several re^ultn usually prwluopd by 



Fin. 74. 



Ornrlon pre(niancy,1cft8li1c. Onlypart of thenvftrypurllripRtrBinthefrcstii- 
tJun cysl. iFmiii I'akvin, ttftifr WiNtKti..) *i. Ovurinti pnttUMUcy. 6. tfitl 
lube. f. Uterus. 



rui>tureof tuhnl eases, nifrereiitijil *^V/^io.»i> well-nitjh iTniX)B- 
ftihle. Trftitmriit : pruelieully the same a« for Luhal Lreiitatioii. 

AiiiHJMiNAi, Prwinancy. — In those canes the oviuii is 
neither in the wonil>, tiil»e, nor ovtiry ; it w in the cavity of 
the iK'ritonetim ; its pniwth is not eurtiiiled hy any resirtinjf 
unwular ^iill. The pre^Mianey therefore may, ami tmiially 
Hoes» po to full term — n history siir[>risiri^-ly dllferent from the 
ru(jtun* (H'curritiL' in other varieties previtnisly ^lesi-rihed. The 
placputn hiiH hreri foiiiul attueheil, in ditlfreiil rjines, to all 
[WirtH of the |«'rilo!i»'um ; to thai eiiverinj: ihe uu-iruH, the 
hhitider, the eolon. the small inteslim-, the niedeiktory, the 
stomach, the kidney, the omentimi. the lumlmr vcrtebne, etc 

Alidomtnal preirimncy is «vid to he prinmrtf when the im- 



190 



EXTHA-VTERmE PREONAKCT, ETC 



pregnated ovule, failing to pass from ovary to tube, drops 
(li»wn into the lyivity of the |>eritoueum, au<l iiltacbinjyr itself 
to ihnt uiembrane, begins there its primary developuient. The 
existence of ihia variety hat* bceti denied and thought to le 
impoeeible ; it i8t»iid ihattlieperitoDeuni would di^e^t the ovum, 
etc. But that impre^'natiou may really otvur in the nlHlom- 
inul cavity it^ Hhown in a <Mit!e where the bo«iy and part of the 
ne<.*k ol' the uterus had heen removed, the ovaries remaining. 
Semen [mnj^td in thr(in;:h a HstuloUH o(»eninf; iu the stump of 
tbu cervix, aud abdomiual pregnancy i'ulh»\ed. 

Pia. 7fr. 



^^, 



Uleroit and ffeCtu In a case of abdominal prc^anejr. 

M«»Ht f-anes of alMlominal pregnanry are j^aid to lx» st^ronrlnryt 
that Le to my, they \te^\n aK tubal, ovarian, interstitial, or 
intra- ligamentous ('ai*es, and aOer rupture beeome, ttfrnndarUy^ 
abdomiual cases. The ovum remains (>artly conneiled with 
its tir8t sac, but wherever it toiK'hes the |)eritoiteurn ii prolif- 
eration of <x>umrtivo ti^vue occur«, and 1*0 the hhct it* eularije'l 
and continues to prow, forming adhesionc to various viKtrral 
layers of j>critx>ueum. More rarely there are iii> re*!lrictiuj^ 
faaendo-membranes, the <>vum, surrouudeil by ilss amnion and 
chorion, l)einjr free in the abdominal cavity. And still more 
rarely the amuiou aud choriuu may a/no rupture, leavljig the 



TRKATMEyr. 



191 



child loose in the cnvily of the ah<lomen. It Ihcn umuilly (li<«, 
Itut exceptionully tlooa not, hut puraiies it.s tievclopmeut 
iu a new sac of prolifcriiti:>(l coniUHrtive tii<&iie, 

HvMiTOMs AN'D DiA<iSosiH. — Nothin'T h]M.'ciMl ofcnn* ilurinjr 
the early jKirt of prc^nanry, excejU thiit thf iitonw dofs rmi 
oiiUir^e (*<(i're.«pnn)liii;;ly with the ihinilioii of [irt'^'nanfy. At- 
liickt* of pain iu the alKlomen iiiiiy »«(:ur. wJlli I'fver. due to 
hK'Jil peritonitis, and s;oineiimcrt pain Is produce*! by fofttal 
Miutions. Mo«t ra^esii progress ttilhuut other reniarkahlc symp- 
toms ; Hometiiuefi there nuiy l>e partial rupture of the eyst., 
with moderate Idei'din^ iMiiJ [irunl ration, and fJuhK'*|iK'tit ro- 
eovery. I-ate in |)rei^n:uK'y the n»ovrnit*u!s uf the rhihl are 
nu>re eiLHiy felt, and the «>uml.s i»f il.s heart iiutrc; disliuftly 
heard than iu lujnnal prej::iuuu'y. The f<etal parti* uiny t*ome- 
linie? I>e distiiu'tly fell through the jMisterior vaginal wall, in 
Doufrlas* tjul-ti*'-m/^. Thi8, however, may also oi'cur in oases of 
hi»a<Tulnted uteri, but here the j>oi*ilion of the os and rervix 
uteri would aid the diugnoHin. (See Chapter VIII, p. 158, 
Fijrure 70). 8mall size of the uterus precluih^ the [H>ssibility 
oi^ itis eontainiug the fo'tus. At fidl trmi lahor-paiiif* Ix'trin — 
uterine eonlraetions — with diwluiru^e oi* the nteriue <le<'idua 
and some bhRxl. and the lietUfi, fill now alive, well, and nor- 
mally *levelo|>ed. simhi ilien. It may renuiin for many years 
without c'hany^e ; or l»e<'onie partiiilly abwtrlK*r|, leavinjr a 
lithopiedion ; or:iL;ain, whieli i.-^ iriM>r i-nninKHi, threy^it iKM'umea 
iuHametl and supptirali>s, the ehthl breaL^^ up, ilH-niiijiosfs, and 
the whole nnitents of the ahsct^es are di}H'h:ir;re(| ihrouju'h fistu- 
lou« 0|ienia>rH iatt) the adjoining visceral eaviliea. or exlernully 
through the nkin. llie woman I»eintr liable to detith from ex- 
hauj^tion, w^ptieu-mia, etc. In eases where a tiiagiaisis Is ahmmi 
certain, it is ti<hutssible to ntakt^ it t^ulff w) Ity pttssing a liuper 
throuirh the dilated os uteri, thuH deiaonHtniting the empUiUYM 
of the uterine travity. 

Tkeatment. — In alHh)minal pregnancy we ollen have to 
deal with a /Av child atid with a develoj)ecl jthcf-ntit, this latter 
not Ix'iug attachfd U) any muwular structure — like the wall 
of the uterus — which will cnnlruct ami prevent hlcHKling after 
aejiaration, hence danger of hemorrhage. 

If the child l>e alive, and the woman present no very eerioufl 



192 



KXTRA-l'TERlSE PRKG^A^CY, ETC. 



syniptomis imthing ahoiilii he done until near ftill term. Then, 
oue of two courflts is available: either '' prhnnty r<tUotofny^^ 
before the child dies, atid iu order that it may be extrac*t«d 
alive; or ^* etfcondary c(£fiotomy" some weeks, or even moiithA, 
after it^ death. Which m the l>ctter plan has long been a 
nmUcr of diwii.«Hion, and still remaiti^ ni!i»ettle<l. liy the 
prinmry operation the rhild in (^onietiniw* saved, hut the risk 
to the imnlier — 10 nintcnuil ileathn in -Ml ranej^ — is iw great 
(ehieHy from iKMiiorrha;^^" iit Iht^ plaeenUil sitf ) that tHHvndary 
cfleliototiiy htw l>eeu until rweiitly preferred. lately, with 




titfaopndlon. (From Pi.AYr4itt.) 

improve*! methmlH of ojjeratiug, the prinmry oj»emtion is 
growing fn favor, and the ehanfe of saving both t-liild and 
mother im*reat«Ml. When the ehild Iish diwi, whether at term 
or before, there i^hould he no operation for at least a month or 
even much longer, provided no Hvniptonm of septineniia aHflO. 
This delay allows (dditeration of the pliuvntal vei»*el« and 
IcfWiiH the risk of hemorrhage during ami after thi- oi>eration. 
It alH> given a chanrf for the " lillui|i:iMlit)u " prorer*, hut thiB 
is sehhan reali/tHl. S» long \\» the dead chihi reniainti, how- 
ever, the rick of Keptiea'niia remaiuH alHi*. Delay nuiHt be 
measured by the ease, not by rule. Some advise the niMhmieu 



HYDATWJFORM PREGNANCY, 



193 



to l>e 0{^iie<i *'a« s-xm us the plactnttal cirnilatiuii linfl censeth 
as verliKed to i>v the Jili.*it»n«;*^ of iiliirentnl niurtiuir." The 
(tperatum (with nil uiitjse(>ti<' precaiitiniip) is done by iimkiiig 
an inciHum in tho tinoa alha. Shoiihl the fo-tjil mv not he 
adherent to the iiluloniinut wall it must he btitt'heil to the iii- 
cise^l snrfnct'H of the wound l>efore hein^ o|)eae<l. When 
0|>eiie<l the rhild ir^ renioveii, the funis cut oH' clttse to the 
pluceuta, hut lh«^ [ilafeiitu Ujt un<tUtittbe<i, to conii? awav c|>ou- 
taueouyjy. whirh it v\il] do afler M>nie days or weeks, the lower 
end of tlje indnion \mt\\i left o|tt*n to [lerrnit its diwharj^e, aj* 
well as for a druinape-tuhe and washing out of the sac with 
ftntiH.'pti(r (iuids. To attempt ^ejiaratioti of the phu'eiitn 
insures immediate and dangerous hemorrhajtie. Even when 
it is left, hemorrhage may occur later. An improve*! mode 
of o|)ernti!i;.' Iul** Ixjen sueeesiifuny [»ructisi'<l to avoid both the 
danger of hemorrhage and wpticamiu. It c(mHst.« in t'xnfri\n<j 
the entire ryd and phrenta at once, not liy tearing or pvelitig 
them away, hut by tirsl clamping and then ligaiiag, )>it !iy hit, 
till vui^'uhir «'onne<'tiou.K of the cyst and placent^L, the [mrtf* 
tie<l hy the ligatures being then wvered by incision. Thi.« 
nierho<l will probably 8U]H^rs4^di> that of le^iving the placentA 
undisturl>ed. At pre**(Mit the matter is unsettlwl. 

When, in neglected cn^^es (without ctidiotoniyj, ihe fietup Hntl 
litjuid contents of the cyist are InMiig gradually diiwharged 
through iiHtuloUM o|)enings, these oj>enings 8lnmld be enlarged 
by careful Htretchitig with s^tcel dilators, anliseittie washes 
thrown in, free drainage sccund, and [lit'cei* of bone or other 
olifitrueting di'liris renKiVftl J»y manijiulutlon. The woman is 
given iron, quinine, food, and sliiuulants to prevent exhaus- 
tion, and opiates to relieve pnin. 

HyDATIDIFORM pREtJNANCY (CYSTIC DEGENERATION OF 

THE C'liORiAL Villi. Myxoma of the Chorion. Vksi- 
ci'LAR Moi.K). — The fwlUB (lics rnrhj, ditwolves, and disB|}- 
pears, or mav be found a^^ a slirnnken remnant of its former 
Belt hurrounde*! by it*? amnion and the degenerated chorion. 
The villi — ihe bidbous ends of their bnuichen — Ikmnjuip dis- 
tended with tbiid into little «m's or cysis of diflferent sizes, 
which continue to increase in uundw.*r lilt rhe uterus is filled. 
Technically, the dJKease is cyidic lor tjropsical) detfeiierotion 
of the rhoriaf ciV/i. The cysts hang by long, narrow pedicles, 
n 



EXTRA VTERISE PREGNANCY, ETC, 

like «liniinutlve elliptic jieare. or dangle from each ottu^r, 
Hiijrj^cstin^ a naeiiil)lHm'<^ tt) serpeiilV ep^ Viewed en mtmne, 
ihey liwk like a hunrh of g^rajx^ but llieir branchinj^ stalk? 
are not (ieriv«l, like a hunrh of ^ra|»e«, fntrn one main Klt-m. 
but one cyst 'i» joined by its |>ediele to anotber, and tbi«i 
nj^nin to anotber, nntil ibe final jiediele i.s trnce<I to the nieni- 
brane of the clioriou. Home* of the cyain are liall' ou inch iu 

FlO. 77. 




Hydatldlfonn degeneratlAn of the choiial villi. 



diameter or a little over — most of them much smaller. (See 
Fig. 77.) 

The degeneratxid villi may penetrate deeply itito the mus- 
cular wall <if the uterus, cvrn to the iteritomuni, and thus 
leail indirei'tly to ru[)lure of lln' ijIitiik In sniiio fj»Mf ^'f 
Iwins the elmrial villi of one fu'fii.s niay deircnHnite. while 
those of the other do not — the latter ehild renchinj;, ifOjisiildy, 
full development. In other caaes only a part of the villi he- 



BYDATm/FORM PREC NANCY, 



195 



cornn? <lifiefl«e<1, enough rciiiaininj; heallliy lo form a placenta, 
ami the prejjnatiry giH's to full U^^u wiili u well-lbrintNl ehihl. 
The de^t'iierarive |>roc^rnM uj*ually het/nn* duritij^ the tirwt month 
of preguaiH*)' : itn oumiiieiiceiiietit \» seldom p()et|>une4l later 
than tlie thinl mouth. 

(^Vjtwipx. — It haj* l)eeii a.Hrrii>e<l to eoiistitiitional HVphilis, 
morhiii chanpea in the (l(»('iilmi, eiirly death u\' the i<etus, etc., 
hut the queMiun i.s :<till uhM'ttli^l. 

Ii Iwu? heen c^Ue*! hifflntuliform pregnanry frf>m a crude re- 
ijeiiihlunce to, and a J'Mrnier firontotut i<up[H)siiiuu that tJio 
cy»U were identieal with, true hydatids (eulozoa. aeephalo- 
c>'st«). sueh an ueeur in the Hver ami uthi-r or^iiu* ([M)eaihly 
ID the uterus), hut whieb have notliing tu du with impregna- 
tion, or an ovum. 

Kt'iiiiKinli* or re|)eated new deveh»pmenlH ut" the LTOWth 
may apjX'ar iiionth.^ or even years al\er irnpre]inia(ion. In 
women sepintted i'rum their hm^bniidt^ uuplfaiumt (implica- 
tions might tiuis ariw. and tlie ciufe aiwume medit-o-legal uu- 
[Ktrlaiice, 

Dkt^nos'iH of True JfiftOttidtt from Hydntidiform Pretjnanry. 
— Ill true hydatifis the cvstj* develop, some itmde of others, 
and the eehinf»ooeci licndsand hftrtkU-ts may ht* wen with the 
niirro«!<»|w. Tlii? microneopir appenraiiee is wanting in hydn- 
ttdifbrm [iroLrnaney, in which, also, wt have seen the oy.sls 
han^ by ntalkh ainl inereaw; hy a port of huddinjr priK-ews — Ht4 
iuHide each other. 

Sijmpiomtt of Ififdnfidiform Preffiiannj. — The early si^ns of 
prepnaney Inllow imprejirnation ai* usual; hot tliere are no 
poeitive or physioil tn^'im, for the child dies lx»fore the tenth 
week — often much Ho«.)ner. Then follows extreme rapidity of 
uterine enlargement. At ssix montlis the wond) is \\» larpe as 
at full-term preirnancy. It ii^ unsynmictrical in sha])e; it ifl 
doughy or Nou'cy to the touch, and no fivtus can he felt in iL 
Overdislention. Iietween the fourth and Hixth nmnths, oct^siona 
oTisiimilc vnmitinj:, and eventually Iwuls tf» coutraction of tlie 
womh, aceom|Minie*l with ^^nslicfl of transparent watery Huid, 
from crushinjj nn<l hurvtin^ of eysti*^ Heniorrhaffo — severe 
henmrrliaL'e — may also <»crnr. 

IHofjimAiH is ciinlirmcMi hy finding ehnraeteristie cy^» in the 
j(li»ehar(iet% or the mass may have l>eeo previously fcdt in the 

uteri. 



19*5 



EXTRA VTEHISE PREOSANCY, ETG 



PrnguoMl;^. — (itMUTally favorable. Mortality 1^ per ceot. 
Tile rliiff (lanjrtT in hetuurrhn^'v. In rure i.'ases rupture of 
the iitpfus may nmir, willi i^oriWMpieiit lieuiorrluige into the 
periloueui favily, [>fnu»ititi^ seplicwuiia, ami death. 

Treatment. — Knipty the ut<?rns an(i secure its contraction as 
800U a» patt^ly pracLieahle. Give erj!;ot. Open the <» uteri, 
if neceiafiiry. with a Itarnes'* or other dilator, ami with the 
fingers or bund, or half hand, in the uterus, cjircfully extract 
the maiis<. Brware nf nijilnriri'j the ttUrhn' vn/i ; it may be very 
ihin^ especially in atlvunffd vwh^ with jrrf-at distention. 
While the ub is diUiting a tjuupnn may Wy necefcsary to check 
hemorrhaj^'c. Instead uf \m\v^ tlu' hand, the mass may be 
broken up with a male metal ciithelcr, and let! to L)ti ex})e11ed 
by uterine coutniction. i*|)ecially wlieu the os is undilated, a 
tam|x)n being uswl to c«nlrol hemorrhage. 

In case the child is demonstrated to be alive {as in the rare 
instane*^ of twins previously mentioned), an attempt nmy be 
made to wutrol heniorrha^re wilhoul emp(yiug the uterus; 
but should this not succeed, and the lite of the woman be 
jeopardized, the rule of removing the liydntiditbnn miii* must 
be udhere<l to, whether (he liealthy <tvum be disturlH-d or not. 

After emptying the uleruw its cavity shoiihl be washed out 
with a cariK)lic solution. If bleeding continue, t»ni|H.)n the 
uterine cavity with ioiloform gauze. To prevent recurrence 
of tlie growth, Dr. Barnes rei-oniuiends painting the inside of 
the uterus with tr. iodin one part to glycerin five jiart^t once 
a week for several weeks. iSlnndd there be any offnufiw dis- 
charge, wash out the uterus with some antiseptic solution and 
insert a supj»osiLory of ioiloform. 

In cases where a diagnosis has l>een made early in preg- 
nancy, or even later, but withuiti autf tift'ri}ie. rontradions or 
hemorrhage, it will behest (provided no evidence of a living 
child l>e present) to dihile the m uteri, bring on lalwr, and 
empty the womb, and thus lessen the danger of hemorrhage, 
which increases willi the tlnrttlion of ])regnancy. 

While the ancicut idea that nil last^ of cystic degeneration 
of the chorion were inidignuiit Ims been long ago abandoned, 
rwent investigation has shown that there is an intimate relation 
between nialignant diwase of the |)lacenlal site and cystic dis- 
ease of the ehoriou. Jl now apfiears that cancer mny nfprnrtim^a 
begin from the diseased cells of the chorial villL 



DROPSY OF THE A My ION. 



197 



Very rurt'Iy llu' cuiitfiits of the cysiic rliorinl villi jM'oonic* 
more or It^i^ soliil fmiii tlic (li>vt>I(>|inient of lihrouH elemeiiU, 
wheu the cximlition i« knuwii as fihm-mifxowtttoiUi deffCHrration 
of the chorion, 

Moi.K*. — M<tleH are ruaisst* uT muxe s*»rt, <Ievelope<l ia nnd 
expellpil from thi^ uterus. If tlie ;;rowl.li riwull rr<<iii irnpreg- 
nulion. it 'm- ai\M a '* true*' mole ; if it occur iudq>entlent of 
iiiiprefjiuuinii, it is a '^fnfj^f" mnl<\ 

Trur iuoli-fi ; Thy Imhiliiliform |irejrimncy just <it«<'ril>eil ia 
ft true mole. Another form — the '^^flmhij nmff'^ — lUTUrH after 
eHrly dealh of the Retus, from a sort of (tevelopmeutal uieta- 
nioq>ho.sis of the foetal nu'iiihraiies, minfrlod with 8emi-4>rgan- 
iwd hkn_Hi-cIol8, so iia to form a more ur lew w>li(i nondew^ript 
fleshy m:iie. C'horial villi may generally !>e discovered in it 
willi the micro«'o|)e. 

Portions of the ftetal memltranesN or of the placenta, may 
be left after altortioii, atul develop into true rnoU^ 

Fft/ttfi nuAv» : An intni-iiterine polypus, or fibroid tumor, or 
retained conrfuhi of infuftfrmti hfood, ur a dt\-^^immuiive aul of 
mttcoug wrmhrnne from the uterine cavity ( mpnd>ranou« <lis- 
nuMiorrhieH), may Ih3 exf^'lh-'d from the vvond), with (wins and 
bleeiling resemhliiii^ those of nl)(»rtion or hvhor. Exaniinnliou 
of the inai*H. it« liistAjry, and al>»eiH*e of chorial villi, will be 
8urtic'ient to itidiaite a correct diaj^nosiH, and .shield the female, 
if unmarried, from any nndesi^rvtMl suspieiouH. 

A deimnamative t'w^i from the mtjina may o<vafnonftlly 
oeciir. 

Theiie are so-called false moles ; they seldom attain any cou- 
siilrrnhle size. 

Trratmtiit ronsists in sccurinfj: their complete expulsiou by 
ergot, dij^itnl manipulation, or curetting. In cajiie^ of Hhroitl 
tumors or |M)ly[ii the UHual t^ur^ical niethtHls muy lie uect^asiiry 
for their removal. 



Dnoi»8Y OF THE Amnion (Hydrammon, Hydramxiob, 
PoLYHYnRAMSios). — The nonnni quantity of liquor anmii 
(one to two pinti*> may he increased to five, ten, uod even 
twenty or more pints. This is hifdntmuion. 

OiffA*/), not tborou;;h]y underst4K>il. In some Instances the 
cause is interference with return of blood to faHua through 



198 



KXTRA-UTERltiE PREQNANOY, ETC, 



iiinliiUral vein, eitluT frtnn prtwuro r>n i\\v con! (ail in twins 
nr (rifili'li*) or from i.li(»e4L>*e ot* f'u'lal lityirl, lun;::^. iir liver, olv 
sLrui'Lin^ circnlutioii : hence ni^K-iiilion of hydramnion with 
syphilitic iliseajje of liver of fietiih. Ext-eHisive secretion from 
thp kidneys or from the iikin of (he fo'liii*. Acute eases wime- 
linies tollow blows n\nn\ the alidomfn, with sup|>jkm1 iuHamma- 
tion of the nnuiion itself. Tliit)n<*ss of the inotlicr's hlootl may 
prwluce iL Tliere are numerous otlu-r thtnireliail explanations. 
It is fieliiom ohfterved before tlie Htlh timnth. 

tSptiptoirw. — Ahdonien unnatunilly Inr^e fnjui ovenlistciuiied 
ntenuf ; increase in size aiul weight of the hitter lead to 4l)*sp- 
nwa ami palpitation, vomiting;, i)ys|»e)isia, insomnia, and (inlenia 
of labia an<l lower limits, together with neura[<;ie alHlominal 
pain and ditfienlt loeotnotion. In cai^-i* of <jmdual arrumnla- 
tiou of Huid, tlie^e symptonifi may Ik* uuexj>ecte<lly moderate. 
Very rarely the disease oeiiirs in an lu-uU form, with fever, 
rapid instead of gradual di»teution of the uU^rujs and ounee- 
queiit intense alxiominal puiu, extreiue dyspuijea, eyatiutus, and 
diatressinj^ enie4*is. 

Hydnimnion amy leuil to or Ih; ;uitMi'.'iati*d with awitee. 

l^ia^noKtM. — The uterine tumor will be found, pn pal])ation, 
elastic and t4?net\ with indistinct tlurlviiuion. Ix'ojuiinj? more 
distinct as the tlistention ini-reases. The f<etn8 is very mov- 
able, rhan^np its [tosition fre^piently ; its heart-sounds are 
faint or inaudible. The history nf pre^^nanoy is ati ini[M>rtaut 
element in diagnosis: it is strnjetinies overlooked. Twin preg- 
nancy diHers from hydnimniitt* in pretH*ntin^ ou ^>id|>atiou the 
solid irregular projt^lious of the two fa'luses. An overdis- 
ttioded bladder is differentiate<l by the etttheter. I)ist4'nti(m 
of the alulomi-n from pre^^naney as»oeiale*l with eystie tumor 
of the ovary or Itroad litranietit ditlrrs from hydramnioe in 
pretfentin^ two tumors of tlitferent shape and eoiisistenoy. lu 
any aiac where the abdomen is enormously distended almoet 
to its ulinoeft eapaeity, a jKwitive tliagnijsis may be imp<««ible 
without an ex|)Iomlive alKlonnual s*?<-tiou, or redurtioii uf the 
fluid by puneture, 

}^i'o*juo»U and Tri'atvtent — Death of the fivtua and prema- 
ture laixir are apt to oecur. One-fourth of the children are 
stillborn, luterferenee with respinition and other fuuctionfi 
of the mother may emlunjrer her life unlt*.SH rupture of the 
floc occur epoutaueoufllyf or the fluid be discharged by arU- 




I 



BTVRORRIKKA. 



Iil9 



ficialltj rnpturinj^ it, wliirh is about all that run be douv l>y 
way t»f Irualnieiit, iumI wliifii. of courHe, oiHtt* X\w prt'jrtmiirv. 
Attempt:* iiiiiv Itc iiia<le to uiaki' ntily a stiiall ptiiR'tiirr uf the 
ainniolic »»■ hi^h u|) l)(*twi-<>ri i\\v. incnihrniu'ii aiul iitrniie 
wall, so us to allow {\\v Hu!«l to run out ;;railually, au«l thus 
Bvoifl premature lalntr. Tn[ipinjr i>t' the utt»ru.s tlirougli tlie 
alxJumiual wall, tor the same purjx^e, batt bevu rtf|>eate(lly 
done, inteutionally, iu the interest of the cbiUI. and without 
any H|K'('ial bartn to the mother, but the uu(x*rtaiiity uf the 
child's life w-Nircely justiHew the rink to her wbk'h i.s in8f|)a- 
rahle from sneh an o|>eralioti. 

When the fluid xta i^uddenly evneuati'<l apply ulMloniiiiat 
bandage to prevent Hyn(*o|)e fnmi rapid reduction of intni- 
alHiominul pri«*ure. Durinir labor beware of uterine inertia 
and hemorrhage, malpresenintioti, and prolii}ise of funis. 

Deficient LigroR Amnii (<)i.n;nnYnRAMN(()H). — Id the 
absence of siitHdeiit litjnor amnii to distpml the amnion and 
keep it away fruru the f<utuH» adhit-ionn may o<rur l>etweeu 
the fujtal Ji^kin and unmiolic niendtran* — they prow together. 
In ea.S4> tlu* detirieut tluid is ret^tored later, tbcrie adhet^iouH 
may stretch into baudn or cords, prodmitig dt'formiti<« of the 
ffVtus or amputation of its limbs. Two liinlu*, in <'ontac;t 
with each t)tluT, may grow together when there is not enough 
lif^uor amnii to se|>anilc them and allow of their free motion. 
There ie no treaUncuL 

HYnRoiiKiKKA (HYORORRirrEA GRAVIDARUM). — DuHng 
the latter months of pregnancy (somotin)e» earlier) women 
olwerve a diwbarge of fluid from the vagina — I'ither a per- 
ceptible gunb rtr a ccjiitinuous trickle or dropping — which they 
think is <lue to rupture of the bag of waters; yet on ex- 
amination the bag ib fouutl *//d)roken. The dis«'harge may 
ot^eur during rest, as atU'r exercise or violence. It is usually 
due to ratarrhal cndomttritii^ — iutlanmuilion of the mucous 
Itning of the uterus. The fluid resembles liquor unuiii Nith 
in mjor and cohtr, but is s<»metimcs niu(V)-purulcnt or tinged 
with bl(HHi. It accumulates Itetween the chorion and di*eidua 
reflexa, until rupture of th*- latter mcnd>rnnc alh»ws its escape, 
perha|^-i in <|UjLntilies of a pint or less ; or it may Ik- forme<l 
chiefly Ity the decidua vera, and escape grndually l>etween 




200 



EXrnA-VTERINE PREQNAKCY, ETC 



that tiiriiihraito iiikI tlie dmiliia refU'xn. ()]>Htri)rtioii (t> tin* 
outflow nt tlw iiil**rnal oh uhri. iir aiUu'Hons l«-twc«'ri the df- 
citlua \i'n\ nii<I rt^flfXii. may a;;airi cjiiuie lunitnuhitiou of ihe 
IliiitI anil its dihchar^e in <jii)tiitity laU-r on. 

A few caKtf have Im.h.mi ohKin'tMl in which tluiil atTiHniilate<l 
between the chorion anil anniiuti, aa shown in Fig. TM from 
Dr. J. R. Nii'iiolsV retwiit puhliraiion. 

The <iiw.*lijir;^f is (iislinguLshtHl from that following rupture 
of the nmiiion in fhat the hitter only oopun? wi^a ami in fol- 
lowed l>v labor. Rare cases are, however, recorded of am»ito/ic 



Fig. 




Afterbirth uUh <Ioiible snc. 1. tiutt^r kac — rhnrlnii fttid decldiiA. 2. Inner 
Mc-amnluD. 8. Chorlonlu CAVlty. 4, AmDioUecavUy. 5. PUcfnia. 

hifdrorrfur/t in wliif*h the autniotir fJuirl has irradiuilly ofiraix-d, 
at intiTVali*, for weeks or niontlip Irt-fore Inl>i)i% lliroiiirh an 
aiMTture in the amnion hi^h vijt in the niernia, lar alK>ve the 
internal os. In one ca»*u tlie amniou had lietin puiiclureU by 
an ill-formed frtta! lM)ne. 

]n nny cai*e, if the disciiarire he sudden find considerable in 
quantity, it may Ik* loUoweil by |>ain and (>rennitiire lalw»r. To 
prevent this we enjoin *\lmihtir nut ami an ojAair, taking cjire 
to avoid llu* rnistitke of hasleuin;^ laltor, under the impi-erNHion 
that the waters have broken, when, really, they have not By 



LABOR 



20t 



this treatment (there is no other) pregnancy may go on to full 
term. The catarrhal endometritis am, of course, only be 
treated after pregnancy is over. 



CHAPTER XII. 



LABOR. 



Labor is the act of delivery or childbirth — parturition. 
The period afler impregnation at which it takes place is ten 



Fia. 79b 




lunar montlis or therealwuts (280 days"). C'liildren mny l>e 
born alive earlier, as already explained, and, except ionally. 
the pregnancy may last as long a:» eleven or even twelve 
months. The pomihUiUj of these latter cw?*}^*^ becomes ini]M>r- 
tant, considere^l in a ine<lico-l<'gal iM)int of view. For pre<lict- 
ing the date of delivery in a given case there are several 
methods. The l>est is that of Naegelc, to wit: (1) Ascertain 



202 



LABOR. 



till* tiay on whicli llic Ia.sl iiu'ii>lru:tliuu ivastMl ; (2) count buck 
three cfifetitiar niottltw; (•i) tnU\ seven (Ihvh. For exnnipW: 
Meuf^ruatioQ iviwtnl Au(;nsl IhU count hark tliri'o months — 
I, r., Ui May \t*t — tuM »e\'eu ilaxti^ wliicli Urin^rs im to May Kth, 
tlie |irolmliU^ duy of delivery. It i:* tlir .Kiime ii*s liut eiiH-ier 
tluui. c'ouutio^r forwurd nine nilendur inonlli^ and adding 
wveu duv:*. To Iw </»iVr exact, the iiuuiher of days to he 
added will dmnieliinfji vary, at* shown in the diuj^rura eon- 
Btrufted by S<'hulze. (See Fig. 7ti. ) Thus, it" iirter rounting 
back three montht* wo reach March, May, June, July, August, 
October, or November, the mjnd>er of day;* to be added is 
seven; if* April or September, ms ; if Dei-ember i)r Januar}'. 
five; if Fel»ruary,/«Mi'. Bbould the pregnancy include Feb- 
ruary of a UMij)-year. the tigunii «iniainc<i in brackets are to 
Ih) addet^l, except when the counting back bring:* us into 
DoccnilKT, January, or February. 

In cai<-ji where ibe 4!atc of tlie ]ii»i menstruation caouot be 
ai^cerlained, or in which the woinrtn became pregnant wliile 
not menstruating, m^ may liap|H'rt during lactation, etc., the 
period of delivery cjin l>e only approximately determined by 
noting the si/^^ of the uteruH and the height to wliicb the 
fund lis iia^ n^M.'n in the abdomen ; thus intimating the present 
dunition of the pregnancy and the conwM|uent number of lukH- 
tiunal weeks JH'fbrc full term. (See page lli'. Fig. (>().) It 
may also l>e rememl>ered that quicketdng is first noticed by 
the woman, tn^utUhj, about the middle of pregnancy (end of 
twentieth week ) in primiparrc, and one or two wt^ek.^ biter in 
multipara* ; but there are many excepliont* to this ui^ual rule. 

Cause OF Labor at Fru. Tkrm. — A num1)er of factors 
combine to provoke uterine contraction, chief among which 
may l>e mentioned gradual distentiou of the uterus near the 
end of pregnancy (not before) from the organ liavitig reiiched 
the physiological limit of it*» growth, while the bulk of itfl 
wmtentfl still continues to inereai^e. 

IncrejiH^l mu!*cular irrilal»ility of the uterine wallH and 
exaggerate*! reHex exeiialiility of the i^pihal cord prolmbly 
ow'ur toward the end of pregnancy, «o that the uterus i.** ex- 
citftl to Contract more readily ; while the stimuli to contraction, 
viz., diHteution, motions of the chihl, t^tretching of the uterine 
lignmentri, prec^ure of the womb on contiguous parts from ita 



LABOn PAIi\S. 



203 



own wi'ip;ht, niul coni|irf>#i(>n of* it by surrrmndiag peritonea] 
uutl niu:Hruiar lay(ii>, uri; ull exii^;;4'rat4-(l. 

When thc^ [>reK-ntin^ |Kirt ul' tlic fa'tiLs (LislfiuU ami pn^iii^es 
u|)4)n tlu' iiftk of the utfnii», 4*<>ninu'tioni* are exciifd (just as 
the bluilder uud rectum <.'oiitruc*t when llielr cuiitents press 
upon and liistvud their respwlive necks), lint, in lalnjr, this 18 
after ihe l>e^nning, heiire irritation of ll»e wphineter {w, uteri) 
CAunot \ye conaderetl the primum mobiie oi' uierine contraction. 

Forces by which the CHii.n i> Expeli.eu — Tlie main 
force is that of uterine contraction, which ilerivon its iKAvt*r 
chieHy by rellex motor influence fron* the spinal cortl ; the 
secoudary or *• acce^ssory " force is t'ontruclion of the alHloni- 
iual muiicleH and diapliragm. Uterine cuntractiuu is entirety 
involuntar)*, that of the aWominal muscles may be assisted 
by voluntary effort in the act of straining.' 



Labor Pains. — A lalwr pain is a contraction of the uterus 
lastin*: for a little time, and then followcfi by an interval of 
rela.xalion or r»'st lu the lic^nnin^f of labor tlie ptuns are 
nhort iti iluration (thirty seconds or Itws ) ; feeble in tUyrtM' ; 
the intervals are hug (half an hour or more), and there is no 
contraction of the abilominal must:les, or slrainin;^ effort. As 
labor prfj;rreHses, in the natural order of things the pains 
gradually increjise in duniiiou, streiij^ih, and the amount of 
straining effort, antl the intervals l>etweeu tbeni become 
shorter, up to the niomei»t of di-livery. The longest [Aims 
seldom excecfi one hundred scwmda. 

The eurhf pains are called "cutting" or "grinding" jmins, 
from the actsuniMinying sensations experienced l>y the woiuan ; 
and thti later oues ** iH-^ringHlown " |Hiintt, from the dLstretw- 
ing tenf^mus or straining by which they are attended. 

lu cases where there is no umlpro|K>rtiou Imtween the size of 

i-* orWn orthp motor p*iw«T of tin- iiU-rii* In »tiU nimt'lllcd. Plny- 
'1111 c*nil'>i)« Alllrnia IhnI tlii- hcl of thr iKitIim ronlrartlniKi 

' ' 'iiiitiirv "i.rnvi.i» tht'in Vt bv vxv\tv*\ Holcly hy tlif »vni|»ii- 

iiihI itirii Ihe motor rmtri' fur lUorln'.'Ci.ntr.i. (i.'.u ■!« 
' ^'.',1 .^..hfpila " (p. -.f.?'. V"Wti?r dVxt I' ■ -1- 

■ •■ *rhr whulf pnn'rfiBnf lutrturltluii i. ■ :y 

Mil' rnT\<iu> ci'iilrr tM-JiiL'i>l>iiM'(l 111 lilt ' 

A. .1 1. iiM« M iii.i [ii»rniv-i*iirtn«' ki'lnnl iK>rvi.'<-»ui>i>lv iiiir 
Ti.t Int. rf. r, M ill, ji •tiitloii or ittNir; mill I'nif, Iliml 
(Te.\l NK»k "f <»i,-t, irl. -. )«ii;'' ■.':t..' .1. ■ Inn- (liiit I«ht.r \n Hctiiany riutliT lu 
wruiiK*n wh'i tmvf pitniiili-tritt. iu» i( ilie it)>liiHl iu'rvi«>t <'xrrrK>it nn inhlMlnrjr 
Avilon upitn thtf uUTitti* tniiKpU*. tlio renifiviil of wbuh riicUlUlr«1 pnrmrlUon 



ftllr i ! 

bt'iii ■ 
thi't 
kn.. 
<.l..v ^ 

On iIk-'.i 
thi.' iM Ivi 



■r \..ir..l. 




LABOR. 

tlio luwl and j>elvK and othtr tliiii;:? are perfwrtly nornml. 
ihere tire stilt tun L^nat ."iihiiictnriiil j^atewuvK whii-h oH'er 
a <vrtnin Himntiil of oIwtnu'tiiMi lo t\w |iiLSf^ip< of the rkiDd, 
and the resistance of wiiich niunt In* ovenroiue before delivery 
ciiu take phice ; the-^:- are: first, the nwiUh of (he uUrus; 
second, the immfU uj ilw rntjimt. 

The " Ba(J ok Watkrs." — A natural arrangement is pro- 
vided for the dilatation and o|>euin;; of the resisting os uteri, 
by tlio pradiiu! forcing hito and pnitnision through it of the 
moKt ilependiiig |nirt of tlie uiiiniolie nac, or '* bag of waters." 
During hilMir-jmins the eontnu'ting circular layers of uterine 
muscle}^ cotniprt-w* the*' bag "on all nde^ cireund'ereutially, 
thuH tending (o make it bulg<' out at the oidy ]H)int of ej^cajH* 
(tbeosuterij; while the longitudinal niuwular layen* in the 
uterine wall i^horten the wood), and thuH (end to pull back, 
or retnu't, the ring of the (*j from oH' the bulging end of the 
protruding hag. The hag, In-iug st»ft, pinwlb, and tdnjilic, can 
more completely tit and fuore easily dilate the m uteri than 
any [Mirt of the fo'tUK hence the imjiortance of not !)reaking 
it during tlie early part i*f the Inlwir. The ireit/ht of the con- 
tained liijuor aninii probatdy iipsisis dilatatiotv. the woman not 
being I'ontined to a recunihenl [Misture. 

The bag of watepH als^j protc^cts the Initiy ni' i'lTtus, placeDta, 
and urnbilienl conl from tlie ilirect pressure of t!ie uterine 
wall ; and it allow:) the womb in nuiintuin it.** aynunetrical 
Bha|>e, thus lessening interfereiiee with the ut4?rine and pla- 
cental circulation. 



Labor ik Diviuku into TriKKK Staoi-:?', — The ^**^ stage 
liegina with the comntencement of labor, and ends when the 
OH uteri is couipletely tliIal*ML 

The jtrrimtl Plage immwliately follows the first, and ends 
when the child is Uirn. 

The Ihirri incln<k> the time occnpie<l by the jteparntinn and 
expulnion of the plat*ejita; it ends with safe contraction of the 
iittw empty uterus. 

Prkmoxitory Symttoms of Lahok. — Sinking of the 
uterus, which usually occurs 3 or 4 weeks before tenn in prinii- 
parte, and a week or ten days liefore In multipane, with cuitse- 



SlOyS AXD SYMPTOMS OF ACTUM LABOR. 205 

<|U«!it ri'lipf lo poupb, *ly.«[ina»ii, ]ialpitatiun, et<\, as previously 
explainwl (pajfcw 169 ami 1*>0). IiKToawMi frequency of evat'u- 
ation^ from l)uwelH and l»Ia<lder from pressure on tlietn of the 
now sunken uterun, C^immenein^ and pnj^resgive uliliterntum 
of the nvrti of the uterus. (Veurrenee of a viwi<l mucous dis- 
fliarge from the vajrina (Oripualiu^f, however, chiefly in the 
een'ix uteri) which may i>e tiiiped with Mood; it ib called 
"tfu ifhou," This la^t lubricates the soft part* and prepares 
them for dilatation. 

Inlennittent pain in tlie womli, due to feeble contraction?, 
may occur a tew days before the actual commencement of labor 
— sonietinteH weeks Ifefore. 



Fio. 80. 




Cumraenctng dllftUtlon of tfao oi oterL ExHinlnnttou with indttx fingcrof right 
luiad. (ARer Parvik.) 



iMiToMs OK AiTi'Ai. Laimue. — Tlie character- 
istic Ri^iH are : 1. I*abor jiuins ; 2. ronunencing dilatation of 
Pf<^.nnA f,r increase if previously existing, of 



HioNB ANO Sym 
istic Ri^is are : 1. A**ti»ui \mi 
the OS uteri ; 3. Preeence, or 



206 



LABOR. 



nuif(>-sa»>ruineouH (lisclmrf^ — the " show ;" 4. Commencing 
descent into or [irotrut^ion throuj^h the Ktt uteri of tiie \n\\i ut' 
wttlers ; 5. IEii|itiire oi' the bu;^ nml discharge ot* Jitiiior aniiiii ; 
6. Kclaxallou ut' exteruai geuilais ; 7. The vooiil outer)', ex- 
[tpreasioa, etc. 

Phenomena of the First Stage. — Feebleness ftinl inire- 
quency of the fir?l "cuilinjr" |»aiiii*. buffering (luriiif^ them 

Fin. SI. 




The 09 uteri more dilAtcd. Exumlnnlfon by finffera of left hand. 
Parvis) 



(After 



\» referreil chiefly to the hrtrk. The wunmn walks nhout, if 
not pn»hihitc<l from \hnn^ fw> ; is rcstlesH. fle8|Mm(lent, perlmpfl 
8Hjj:ht!y irntnliK- from (iiscontent at unf^Tcst* Mnft slow. 

Ab WilntAtiou of the os uteri proj^ressvs, tiie pains become 



208 



LABOR. 



or even sovore ripore ootMir, l>iit without iiny f*>vor. Full (iiUi- 
tiition vt' ihi* «w uteri is UHUailv aimituinfd by ru|jturf of lli« 
bug of waters <lurin)^ a jmiii ami uti auilil>le ^iiAi of licpior 
uumii.' Uu vugiuul examiuutiuu we tiuii biiiii>ly prujrrttwivo 




Q^l 



^ 



UeiLil III vulvitl opeiiinu ilishiiOing i»or!neiiin. (ARt-r I'akvis.) a. <*aptit nic- 
cedAncum. b. DiHtendcd perineum, c. Anus. <r Coccyx, on line of rircurofer- 
eneo of dbtUmded urea. 



dilatation of the os uteri and prolruaion of the bag of waters. 
The prest^ntiug [Kirt of the chilil may be felt through the 
mibrokeii sac. The duration of the first stagin varii'S much 
iu different eiwe** ; it is nearly alwayt* iimrh longer than the 
other two Btages coniltined. It is, indeed, a nmimon obiterva- 
tion that a longer time is required for the or uteri to dilate as 
large afi a silver <!ol!ar than for nil isubf*<*ijuent parts of the 
labor together. The first stage is u-siiiiUy longer in priniipar- 
0U8 women, and still more eo iu |)rind|iara* over ihirty years 

* By tome milhors, ru(»t(tre of thp has duilncs Ihe end of the nrat ittiiRD ot 
labor; H may. however, (ire-cede dilaMllon, 



PHENOMENA OF THE SECOND STAGE. 



209 



of age. An 09 ut<»ri thut is t^oft, thick, ami elanti*' ililiili'S more 
readily thau n hiin), thin, rigiil i>iie. Pn^timture rupture of 
the bug of waUTS greatly impedes iUlatiUiun. 

Phenomena of the Second Staoe. — Tremendous in 
creai»e in the frwiuenoy* strength, duration, and expulMive or 
bearioji-^Iown charnctcr of the fwiiiis. Nevertheless they are 
more contenLedly borne, from i,8Uj)|H»8ed) amsi-iouHness of |>rog- 
rew on the part of the woman. The hea<] of the child may 
DOW be felt deseeudiug into and }>eginuing to protrude through 

Fia.M. 




IICAd «hottt to|iau the rulvnl oprnlnir. (After PAKTm.) 



the ofl uteri. Tt eventually slipB thronph the ob into the 
vaf^ina. af.*n>m|)anied with renewo<l flow of aonie remaininjf 
rupior nmnii. There may l>e a momentary nauw in the Huf- 
fering, and the wnniait may exclaim. "8ometnin^ ha» eorne !" 
The head now prewinp upi>n sensitive nerves in the va^'ina 
elieitrt still more reflex niutor pt)wer from the spinal eord, and 
the [wiuH are still lonirer, Htronjrer. more fref^uent, and ex- 
pulHive. The rornij^rttrd walp of the ehild. Hwollen anil 
(wlemuloiis (eonntitutin^ the niput nuccr^nuenm ), *>uceeesively 
approaeheA, touches, and l)eginfl to di«tend the vulva and ihti- 
II 



210 



LABOR, 



neum. The amis is dilntefl and everted, fecal matter is forced 
oiil, the |M'rineurn is stretched more and nutrc until Jl8 nnteririr 
IwinltT is iilniust to* thin as pa|«»r, and at last, in a L-limax of 
siiHiM'iii^, the e<nmlor of the head slijw throtii^h tlw second 
»phiiu't^>riul piUeway (tht:! 08 va|rina-). and the head is lx>rn. 
A minute of rest iiiiiy tollow, and tlu'ii, with oue or two more 
iwiiius, t!ie lioily oi' the t-liiltl i.-* *'X|K'lhMl, and ilie wiiond Hta^e 
of hthor iri over. Tlu' tlnnition of the HtM-oml slit^'e lar^rely 
defieiuls upon (he dilaUdillily of the |H^rJnt'UUi. In a natural 
taB4', other thiii^'w i>ein^ I'lHial, u soft, thick, ehictio i>fritu*uin, 
with altuiiduut nnieoiiH di.^'Iiarijre, and in a younjr and mul- 
ti|»arons >voman, will dihite WKaier than when opjtwite condi- 
tion.s prevail. 

PifKNOMENA OF THK Tnmi> .STAr.E, — By the time the 
chihl is fully exjK'lled the jilnoenla in often in-parated from the 
uterine wall and lyini: lortse in the now contracted uterine 
euvity. The womb may 1h' felt lus a liard, irregularly j^dtdnjlar 
hall ah4)ve the |iuht>. Tln-re mity he an interval of one- 
qurtrter or one-half of an lionr's rest from painH. if the eaae 
he letl entirely fdone. Then, WHijier or later, jreutle |Muns 
apaia eome on» the plnreiUa is dnnhled veriically, the f<etal 
surface of one half in HpjKisition with that of the other, and 
the organ protruded endwi*k' into the viitrina, ihmi whenee it 
is, hy other i*liiriit jtaititi, finally exyw lied, together with pome 
hlo<xl, remains of liipior antiiii, mend>nini*»t, etc. The womb 
now eontnu'ts into h diHtinctU' ^lidiuhir, haril ma.-w. m) l>ijr)ier 
than a erirkel-lmll. Ihns elU'etually rl(k-iiii;r the nteriae hloo<I- 
ve«*el» ami prevenlinjr fienmrrlinire, which hi^t i?= further 
6top()ed hy eongulatiun of blood in the months of the oj»eu 
blcMxl-cliauuela. Thus ends tlie third stage of hibor. 

Thk Vck'AI. (3utcrv, Exi-ressuvn. kt(. — These vary with 
the different stages of lafwr, and with the different ]»eriod^ of 
eaeh staj^e, and even with diflerent painn of the pame jK^riotl. 
At the very lie^innlnjr '►f llie first Hta«e, the woman, l>einp 
reativv and [>erliiips walkini; alnjut the room, kIo]»h lor a few 
mtiment**, frowns, plaer.M a haml upon the ahihmien, or buck, 
h(»lds lier hn^ath in silen<'e for a little lime, and then, with a 
siph of relief (the pain heinj: over) ^roej* on walking and talk- 
ing as before. A little later, when the suffering beeome.« ?nf- 



MAhAGEyfENT OF LABOR. 



211 



ficient to canwi an amhble jjroan or outcry* it will be nutic*e- 
ablo Mint the cry oi ttie wirlicr |>iiiii8, duriug t'oninifiK'ing 
dilatation of the os uti-ri, in usually of fi liif/h-pitrht'tl, frrUc 
notr — uot unlike the jiliiiutive whine of a sttlernlog grieving 
for its al)«?nt master. So lou^ as this kind of outery eon- 
tinuen, tliere is |i;;enerally t*low pntgreisf only. With later 
and more effective paius, ef|>eeially towanis the end of lulior, 
the note of the outer)' is of a t/etyA ffaur, or ^'ullunil character. 
Tlie best (L c,, most effeiTtivej pains of all are lliuse in which 
there is actually no romf itound of any kind : the wcmuin, with 
cloeetl eye», conipresse*! li|»s, and general contraction of (lie 
facial muscleii, simjdy h(dilfi her hrenlli ( until nearly*' blue 
in the face") and mtrain^ with oecayioiuil brief jactitaliuiial 
es|>irntor)* and inspiratory pHsi»e>, until the pain it* over. Then, 
having regained her voice, jelie declnitiis in liurried and vol- 
uble terms the iutensit}- of her agony, the demand for help, 
tiie inability to hitar it any longer, and the belief (perhajw) 
tLat she niuHt die, etc., etc. 

During the earlier pj»ins the Imnde are clenched and the 
arniB forcibly flexed. Later on. and eontinuoui^ly until the 
birth, there is a dii^jwitiition to gnis]) and pull any object within 
reach, usually bcd<*Ioi[iiug, or the band of an attendant; 
while steady pressure downwards is made liy the feet upon 
any firm supi»ort avuibibje for that purpose. 

This dit<|M)Hitioii to grasp and pull with the handn while 
making preswure with the soles <d' the feet, is probably the 
rudimentary [<tirvival of habit, ac(|uire<l by our sylvan ances- 
tors ages ago (and still in vogue with Sitme uncivilized 
peoples )» when women were delive^e^l in a «|uatting popture, 
the haudh, meanwhile, grasping a napling of the wo<xI. or a 
stiike driven in the ground, to steady ihem during the procens^. 

The averahe duration of labor nr natural cases is 
nlxMit ten hours. It nmy 1h» over in one or two hours, or last 
tw'enty-fotir or longer without any had consequences. 

Mana<jemknt of Labor. Preparatory Treatment. — 
In anticipation of a])proaching lalN)r, preniutions against con- 
etipation, by nnld laxatives f(-n^4tor oil, nuinim, rhubarb j, may 
Ik' necet^siry to prevent fecal accumulation in lower bowel. 
Moilcnite exenMse, as far as practicable in the open air, and 



212 



LABOR. 



chwsH'uI iMK'ial Hurn)iimiiiip:8, to rnili^Rt^; despondency. Phys- 
ic4il and mental excitement murt he iivuided. Awertaio 
whether nrine he voided frwly ; if not, use male elastic 
cjitheler. 



Preparation fob Labor A5D its EMERaKNcres, — On 
l>ein^ ('alle<l to a lalnjr case, the physician *>lioti]d attend tnth- 
out deiuy, and take with him nhrofji* the tolli>wing articles: 

1. Compressed aatiseplic tablets of bk'blonde of mercury.* 

2. A i>air of olwii^trie foree|»8. 

3. Fluid extract of ergot f Jij. 

4. HypfMlermic syringe, 

5. Hypodermic tabletif oi' mori^hia, strychnia, and uitro- 
glyeerin. 

6. A Ptethoecopo, 

7. Needles, neetlle-holder, and a»epdc fluturee. 

8. Male elaiHic eatbetor. 

1). A Davidrron or fountain syringe. 

10. Iodoform gauze. 

11. <'iirboIic aeid, ,^ij. 

12. Boltle of carlwlized vafieliue or mollin (5 |)er cent). 

13. C'reolin, 5ij. 

14. Sulphuric ether, ()pg. This lagt, being bulky, may be 
omitted, if it can l>e obtained within easy distance of the 
patient 

Physicians do not generally carry all these things, and prr)b- 
a!dy never will until coni|)t'lled an to do, an they .ehoidd be* by 
law. Mtwt of the arliclw may be M^ldctm wanted, but emer- 
genciefi known to \\e probable shoubl be antici)>ate4l. In addi- 
tion to t.he(*e arlicles! carried by the phyhician, the uun^ or 
|tfiticut should be instrurted. Iwfore labor l»egin8, to have 
rea<ly alw» : a t>ed'|>au ; an iilHlominul binder; ligutureti and 
sdfi^ors for the navel-string; a pint of whiskey or brandy; 
two or three rolls of anli.-k'iHic alisorbent cotton; a fectUng 
cup ; antiseptic pails for the hjchia ; and plenty of clean towels, 
hot and cold water, and a paper of safety-pins. 

Antiseptic Mii>wifkrv and Anti.sf.itio*. — At the pres- 
ent time no argutnent is ne<*essary to accentuate the irnimrlam* 

I Tlje tablets I UH Are those of Dr. <;. M. WMium. rtmtiilnlnK hydimrg. Mehlo- 
rid. gn. T.T, unmon. cblorid. gn. 7.3. >ladc b> WxcUi A Broa. 



AUTISKPTIC MUiWIFklHY AND A.WIiiiiTTICS. 213 



of A rigiti nntiBeptic hrhuuiur in tin- rimnnL''(tiu'!U of liil>iir and 
in ol»*tetriL*al o|jenitions aiul |)rtK'e4iurt'?' of evi*ry kiml. The 
auti^eptio iiietlitMl hah almost rorii]>Ietely htotted out piier]>eral 
fever fruui Ijing-iti iM»*|Mlalt!, when*, iu forimr years, many 
woni«u <lie<l from that (lipase. While iu private pniciioe, 
with iiornml hvi^neiiif tiurrouinJiiip*. the mortality from septic 
infwtion. withoiit aiilisepticsi, iiiny hy an'^lental jjotxl luck he 
cotii|>anuivt'iy r*iiinll, it is trxaetly thiri small mortality from 
which «vt'rv woman ou^'ht to txptn't, and tlfiiiar<l, jiroif^'lioa 
at the hamlti itf her iiieiiifal attendant. \\'licii prophylaxiH 
ie po&iil>le. the liahility to di>^a&e and death eaimot legiti- 
mately he left to t-hanee and luck. 

The real reiitMui why autiHcplie uiidwifery had failed to 
receive iu private praeliee the nidversjil adoption which it 
deserves is not so much lack of heliei iu its ettimey, hut lack 
of knowledge un tti the nitthod of (trocedure, difficulty iu the 
selection of one method from many others, and patience in 
earr>*iu;Lr out detjiilt* of whatever pluu may have l»eeu ch(»N'u. 
To fH<:*ilitat6 and siuipliiy the matter, the foilowiug directiouii 
nmy he t»f .^erviee. 

AutUeptifj SoluiioiiH. — Three antifippties, now iu eonimon use, 
ftre bivltonHf of mfrc-ury, creoUn and t^irbolic m^hl. The 
stroujfer hichloride solution ( 1 : 1000 ) \fi. made l>y adding ah*uit 
seven and a half graiu^ of hiddoride of men-ury to one pint 
of boiled water ; mont conveniently and more exactly done l»y 
ueiuji; the eompresHMl tahlet^ uttw iu the market, each eontuiu- 
ing 7.7 grain** of the bichloride, rjvirf /»/ putficifnt to make the 
1 : tOOO s*dution. Of courRt*, 1 : 'J(W»0 or 1 : SOOO. and 1 : 4000 
solutionii are made by atldiug the same amouut of bichloride 
to 2, 3. or 4 pints of water respectively. 

The strong solution of curbvUc nrki ( I : 20, or o per cent) can 
be niaiie, approximately, by abiding f^^vj (tnx snuiU teai«pO(m- 
fuls) of carlM>lic acid to one pint of water. Thit* strong w>lu- 
lioa may be usted to sterilize inMniment.**. but a weaker pre- 
puraliou — .^^ij to the pint of water — will be usful for the vaginal 
or uterine douche. 

Vrealin dm^ not diKs<ilve in. but eawily mixes with, water to 
form a milky emulsion, the flreugth of which, for douchiug, 
dhould l>e from 1 to 2 |*er cent^-uAo«^ Cy (or ft auiall te^ 
s|M>t>nful ) to one i>iut of water. 

Of tluwe thre<^ the bichloride i» the liest genuicide, espe- 



214 




LABOR, 



daily for oleaiiFini^ the exUTim! jmrte. Cretilin i« wifer for 
tlie iuteruul lioucliiiig. Carbolio oci^l, in strung solutiuii, for 
inslniiiientK. In niakini; cithiT preimraiion. n^e first a little 
hnt water >vith llm gfrmiridt*, then mli\ the rfijiiireiJ ijuanlily 
later. 

The antipeptic mauageinent (if normal labor aims to jn-eveitt 
infection. Thic prophyluxis iM>nHi!«ts in tlioniuj^h disinfetliou 
of the paticttt, the phi/niriany and llic lutttrumndt* an<l ajffiiiancfS 
employed. The >:iniplest metlioil is* ns t'ollows: The fHideittf at 
the beginning t»f lul»or, Uiken a tcpi<l hath, and \s well wruhlKHl 
all over with ^aj) atid water. Thru an eneuia of R»ap and 
water to enijity the Iniwel ; urter the aetinn of whieh, the 
external j.'e[iiialsi. thiirlis. buttocks, and abdonu-n are earelully 
washed with a 1 : "Ji)Ui> birhloriile w>lntinn» special attention 
h)e!uj» j^veu to overlook no fdld or fissure of thp Kurfaee, 
Finally, the vajrina ih doiirhed with a 2 jxt cent. (Ttulin dilu- 
tion, or, in plaee of this, the 1 : 2()(K) hirhhtritk- KiliMitm. The 
utility of thih vaginal injection is ([uet^tionable. l'nlf«: there 
be some special reaKm to fear an already eiij^tin^ iniW'tion it 
may be omitted. It Wfuihes away hibritutin^'' nmcub fnun the 
vani^ina ; and ex|^»o(*ei> the woman to the awidenl of uifection 
from the upe of an unrlean Hyrinjrf. The phii'^innn, before 
Diakinp any examination or doinjr any o|ieration, removes hip 
coat, bares the ariuj* to above tlie elbows, when the hand? and 
arms are tliorou^ddy wnibbed with Mm|). water, and a KtiH* nail- 
brufh. l*MTHiM? the nndi-r surfaif of the nail-ends anti the 
ft^urefl .'JurnnnKliii^' the nnil.s with nmie jxiinted iI:^lrument, 
not sharp enou^di to scratch, and having' whsIihI oH* all i*nap 
in Bome clean water. imnieri*e the hands and lave the aniiK in 
a 1 : 2000 bichloride wjlulion, and ctmtinue thi^i hist \va>hing 
fur five minutes, rorcej*?. fuul other metal iuMrumeutt^ »ln.iuld 
lie steriliz«^d by immen'itin in a T) \mr cent, solution of carbolic 
acid ; or they may l»e wnipi»ed in towels and boiled for tea 
minutes. S|«M*iul <'an' to lx» given in cleantinf; joints, fisxnres, 
and KTews, and the nozzles of syrinjres. All sofV lexturol 
fabrics — cotton, lint, etc. — to be Ftcrilized in the Inchloride 
(1:2000) solution and wrung out, before cominjuHn contact 
with thepeuitak iS;;*)»</''jf nhould lie abolisheil from the lying- 
in room ; it is almost impossible to diiiinfe<.'t them. 

It 18 uee<lles» to add that any tuinres used (as in sewing up 
a perineum, etc.) must, of course, be aarptiv, as in any other 



AJiRA^GEMBNT OF THE yWHT-VBESS, 215 

surreal operation ; and Bur«pj* must he Bubjected to the same 
di»iufeftiuu as the physician, RiihlK>r t-lnihs ainl oiU'd imii*lii» 
or silk mav Ik' sterilizeil hy nihhiii^ llinii with ihr hicliloridt^ 
Bolutiou— 1 :'JO(»0. 

The detniln <»t' antiseptic techniqutt, during ihewvenil stiiges 
of lal»or, <)lwtetri<'al ()|K'r:itioiiw, and tlie puerpurium and \\.a 
diseases, will l>e given iu their ujjpropriate places. 

Preparation of the Woman's Bed. — Tjet it l>e anything 
rather than a feather l)0<i — a firm niattrci^ is heat. Phice it 
80 as to l>e approiu'huhje on hoth tiides. Cover it \vith ii rubber 
sheet-, and over this an urdinary iK'd-sheet, I'Vsteu thcst- two 
to the inattresH with safely-piny ; they are tint to \w. retiuived 
after hilw^r, but over them are phn'cnl u sccntid riibl»er sheet 
and a second ordinary sheet, fa.siened iu the satiie manner, 
which fire to be removed atler labor, leaving; ihc first st-t ch'an 
and dry. The ordinary sheet of the aet^md set HJinuh] }>e 
turned down from aliove until the line of fold is helow the 
womau'a shoulders (the ruld>er sheets need only cover the 
lower two-thiniH of the mattret«), iu order tt> facilitate its 
withdrawal from Inflow, when hibor is over. Diirinjr labor, a 
pud alwut three iucht* tiiick, and two or three f*vt .^(piare. is 
placeil u|)ou the second shi*et^ I>eue4ilh the woman's \\\\va, to 
rweive al! diwharp-j*. It may be made of fohled shtM^ts, or a 
soft blanket, or, still In'tter, of oitkum, jule. cotton, or some 
ctlher nl)*>rbe[il material, pncke<l in a ( hwAc-cloth bag of 
pro[H.'r size. All matiTJals, blankets and sheeting to be th*)r- 
oughhj Mer'dizrd before l>eing used (see |mge 214). When lal»or 
\s over, the upper rubber clolli (No. 2), with its soih^I slu'Ot 
and soildened pad, may l>e easily dragged oH' at the f<K>t of the 
\wa\ leaving the imtirnt n-stiiig U|kui the dry shrct (No. 1) 
first phicetl over the rubU-r cloth (No. \) fastened Ui the mat- 
tress. 

In.stead of the abs4>rb«nt pad* the enoutchoue pad. ileviMMl 
by Dr. II. A. Kflly, may Ik* u?e<l. It not only pn»tects the 
sheets, l)ut conducts discharges over the side of Lho bod into a 
vessel ou the ficK)r. 



ABRANOEMrNT OF THE NiafiT-nREfts. — Its Rkirt should be 
rolliMl up to ihu level of the armpits or a little lower, si» as tft 
l>e out of the way of vitgiual dis4-hai-ges, while u thin [>etticuat 



216 



LABOR. 



or light flaunel skirt covers the partjs helow the wai^t. Wheo 

lul>i>r ifl over tlie suiltwl skirt may be reaJily removed over the 
SneU without IrtlinR the |tatieiit, and the dry night-gown then 
pulleii down from alwve. 

Examination of the Patient.— 1. Veriml examination, 
in a» gtnitle and pleasant a manner as ixeiyihle, into the child- 
bearing history of the patient, a.s to uunil>er (if any) of pro- 
vioiis lalnirs ; their character, duration, and romplic-atiooB 
(ei4pe<ria]ly as to fltMHling uft^r delivery). Did the chihiren 
survive? Symptoms during pre**cnt yrajnancxfy if not alre-ady 
asi'ertjiiued. Hiw it resiched ftili term? Present symptoms 
of Ittlior? Pains — their fre<iueney, severity, character, aud 
duration ? Cliaracter of the flow 1 Has the liag of waters 
broken ? 

2. Abdominal eianinmLJon, to ascertain, by pnljMition and 
insiieetiun, the .size and i^hajn* of the jjravid ntern.s, the pn^en- 
tatinn and |M)sition of the child, and the exi>;lence nr utherwiH3 
of tiinltiplo prejj^nancy, cornplicaliny^ tuinnrs. Iivdranunos, etc. 
On ittfipcvtiiifi, the [tmrliced eyr re^ulily apprpiiiili'S any marked 
departure from the UHual r^yniruetncal fiirm ami nrdinary sixe 
of the nonnni gravid uttriis: also deeidetl nuilforniatiou^ nf 
the woman's shape, indirnthi^r |)elvic deformity. The greater 
width «if the al)d(inien, in a IransvertM; or (jblique dire<'tion, 
visibly Hu,ir;;cj<ls shoulder pr*'i*i:Mitatioii, Su>tpicions aroused by 
inspeeiion to !«• ronfirnuHl, or utherwise, by fudjKUUm. 

The meihoih uf palpai'um here given relale oidy to normal 
cases tjf heiwl presenttUion.^ The woman licji ujwn her l>ack, 
the biwer limhs straight onL, and the feet slightly ftej>arated, 
or jwirlially flexed with the heels t<>gether : i£ comj'ktctif flexed 
the thighs come in contact with the enlargtN] abdomen and 
otiHlruct the exanunatiou. The bladder and rectum mut^t be 
empty and the abdomen bare, except perhaps one layer of 
8t)nie tliin faliric. The manipulations to lie practiced onlif in 
the nbs<'nce of uterine contractions — between the jMiins. 

The educated hands or lingers will recognize the ibUowing 
characteristics of the several parts of the diild : 

<i. The h*'<ni : it feels hard tnu] gfohuhir — there is nothing 
eie« like it — if not engaged in tiie pelvis it may be made t^ 

> ftlMtInn In otht*r cane* will br mnaldrrrd In retatlon to tbe Utaonotia of ih« 
WTcnl prcientatloni ftiul Abnurmal eoinpUcatiotu. 



EX A FIXATION OF THE PATIENT. 



217 



BWiUQ or move from Bide to side l)etween the hnuds — u reiil 
ballottemeuL 

b. The brerch : it feels mfl aud irret^ular — (juile differeut 
from the cTnnium. 

c. The htjrk: it feels like a firm rtttisi'mg plane surface, or 
one side of a long cylinder. 

Fio. 8Sw 




Flexluii uT the liriid, mnkiri^ the otvip^t ilrtcrml wlw\ ihe ftfrekead rtae. (Fnitn 
Davih, afWr LKurtti.h.) 

(/. The ab(iotnen : the uhdotniiuil ns|xx't of the child is oov- 
ered by the extremities anil lir|nor amnii ; hence it ft*el8 mft, 
ffoAtir, and i/Hres'uHlih^', with irntjiihir prtijrvtwna (tht* m»|K*r 
and lowf-r limlw), whirh niny niov<' actively (tr 1k" moved hy 
the exaniiner — vitv diUerenl from the Knn, resisting |)hiae of 
the childV hfR'k. 



218 



LABOR, 



tf. The forehetul and itcciput: the h«ul being usually /foy*^ 
tbe (X"ci|»ut will \w tilteil tiotw lotvunl the fulvU and it** jmstr- 
rior projcrtiort rt'ductii ulnnK*t to ti ci»ntinuuti(»ij ot' tlie plmie 
surface (»f the ba<*k and na|)e of tbe livtk ; heiifv the I'xani- 
iner's iintrers reat-li it with diHicully or fail to toueli it at all ; 
while the /wrtf/ifcu/, buiug tiffed upivufd und j'onmrd toward the 

Fiu m. 



PftllNiting hiwtl lu lower iwrt of uterns, but nut yet In jiulvle cavity belrm liriiii. 

ooterior plane of the ehiJd, Itecomefl wore proininettt^ and is 
fOAihf ffcoguh/'d — it feels harder, larger, and higher above the 
brim than rhp oeripnt (see Fig. 85). 

/ The globe of the prest-nlinij head may be ahovr the pcfric 
brinu or may liave dfju^fjidnt, more or U^ss. into the pehic 
catrity. In the former caae the examiner's iingers dip l»elow 



EXAMINATJOS OF THE PATIEXT. 



219 



the brim. au»l fiiul the pelvic excavuliou empty ; in tbe latter 
aibt% ilesfcut of the head into the hrirri fills the ppat'O, niul the 
fingers cauiiot enter the inlet of tlie excnvution. If, h'Jore 
labor, or during iU bajinnimj, tJie prc^euliug part de»c«iul into 



Kio. M7. 



i 



^^^m 



V- 



/ 



/" 



PaljiHtlnK tiriTch. (After Davis.) 

the excavation, it us a Head presentation : no other presi^ntatioa 
will do thia. 

In |jal[MitJn^ the alKlonien ex|.)erieiiee hiu* dcnionjitrated the 
folhiwinj; serit^ of suocerwive nmnipnlationt^ to Im- advisalile : 

Fird. The examiner, heiiijr at the Hide of the piitieiit and 
facing her, plm>e« the paWii8 of Ixilh hand** acroM the alnlomen 
hIm)vc the umhiliens — the finger-lipH of one hand touching 
those of the other — then pliiles the hnndf* upward with ffentle 
pressure until their euhital iHtrders i^ink in uhovi* the ftimluH 



EXA^rr^\4Tloy of the patient. 



221 



Third, One Iiund only is nse<l : it is pliiot?*! arroM the low- 
est [tart of the mi(Mle of the HlMJonien jvi£t alxn'e the fulies, 
its ulnar b<inler l»ein^ t((wanl the nions veneris; the tliumh 
on one iimIc ami fiutrer-ti|tt» on the other then attempt to ^Tiitip 
bo<Iily the pressenting head, it* hard cuusbteucy and delined 



Fig. 8». 





¥ 




r,..?.. 




/f' 



Pftl(«llng IibM f kibtilnr tica<1. wllh one hand. (Prom Davi9, after LBocni.li.) 

ghihular j^ha|)e t>eint; endily <lifitinguii<thed from the ill-<lefiue<l 
outline and ?«»ftm'»4 of a hreeoh «u»e. (See Fijr. W) 

Thf hand laiiv Iw phu-etl hijrlier or lower, arcordin^ a^ the 
head lias or Iimh not deMvndc-d inlu the [H*lvi<' fxcjivHtion. 
In either riuM> the forchrml will l»e more prontiiieut aud mor« 
eAlily reoogtiized than the oerijnit, iis alnuidy explained. 



km 



222 



LABOR. 



Fourth. InMejid of the thiril manipulation just previously 
cie»rribctl, the following iiietliod uniy Ir* hm^A : 

The examiner, tilaiuliug wilti liit- l>iu*k towun! the jiatient's 
fftce, pla(*e8 liis ItamlH on t!ie alwlonien. alnnit tour inches 
apart, ho tliat the finger-LiiJH tuuc:h the up|)er margin of tiie 
puhic rami, v>\nh the thumlw jwint toward each other at 
ahiiut the level of tfie uml>ilieuR. Now U>t the Hn;_'-er-tMHlH 
push hetbre them a shallow f'olit of the ah«himii»il wall down 
iK'twtX'ii the pn'set*ring hwui mul jH>sterior a.s|k'('t of ihe pulno 
hone:* near the ilia-|HH'tineal emJuenee. The fingiT-eisilH thus 
actually enter the |H'lvic brim Moir the iietnl. if the latter 
have not il«*ceafled into the exc^ivution ; or, if the head hare 
80 de(jeende4l, the tiagen» cannot enter, but reooKuize the head 
obstructing their |Hu«a^e through the brim, the more promi- 
nent /roH/«^ region Iwing recognizable as orteriug more ol)i*truc- 
tion t^) the baud ou tknt side of the (>elvi8 than i« offered by 
the pole of the (M-riput on the other side, whore the finj^erH-nds 
can penetrate a liule deeper. (Hee Figa. Mfi, JM>, pp. 'JIW, 
22'1. ) If the abtloiiien sag I'orward, it may witli the |ndni8 of the 
hands lie lif\e<i up a little out of the way, and thus facilitate 
the entrance of the iiuj^cra below ; and if the iiliduuiiual wall 
be tense, this may be partially relieved by the hiwer lind»s 
being slightly flexed, with the knees ajwrt and heels tofreilier. 

Tile prenentativn of a head having been demonstrated by 
these manipulations, the jHmtion of the occiput will )>e also 
known by observing where the Inick is, and whether the prom- 
inent frojifal region be liirecte*! nntrriorly or jtojttcriorifj^ to the 
riflhi or to the h'jt. With the aUhmiinal examination may be 
included extenml pelvimetry {which seej. Every pregnant 
woman should have her [lelvis measure<:l early in gestation. 
If jireviously omitted, it should be done later, either l>efore or 
during labor. 

3. Vaginal examination. To the young practitioner, who 
may experience some embarrassment with his first vaginal ex- 
amination, the following suggestion.s may be of service: 

In labor caeies it is vot neceteary to obtain verbui consent of 
the patient liefore instituting the examination. Proceed (the 
woman being in Ihh!) without heriitation, as if consent had 
already lu^eii ol)tained. Having been wnt for t(» attend her 
is a sutticient gnarant<'e of this. If anj'thing is to be soid on 
the subject, some such remark as "Well, we'll see how you 



J 



EXAMINATION OF THE PATIENT, 



223 



are getting on **— euitinj; llie action to the word — will he 
amply suffiriont ; or n siniplo inquiry ii.s to the oonveuicucc of 
«»np, water, mul towel may l« eiiou^rh tti iiilroilure llic suh- 
jei't uu<i imlitmle one's purporH!. The leaa tiaiil tlie hctter. Fro- 



Fio. 90. 



X 



.-''^■ 



K '. 



PA]|Mitlon Willi head In peWlp rnvity : flntrorn townnl the occi|mt enter deeper 

limn tlitiet- toward lorLhonrJ. 



ceed, ^i*ithont hftriinfion^ ju?t nA in feeling the puW. Should 
the woman ery. ilemnr, ami deelare she ennnnt pulmiit In the 
exnmiimtiuii, procee*! juKt the Mime, meanwhile n<Klri'Ksiii|; to 
her any kind ward of* en<Hmnitremenl that nmy »er\*e to lenien 
fear or emharrussmcnt. Nothinji: hut phfnrttf reffintaure on 




224 



LABOR. 



the part of the woman should induce the physician to give 
up the eiaminntion. This will seMoni occur ; whoii it dnea, 
there is nothing to do hut withdraw from the casOy or the 
announcement of this itUeniion will generally remedy the 
dilficulty. 

Should the (Mitient he dressed and sitting up, she must be 
rtH]uo«led to go to her room and lie down in order that the 
exnniination may be made. Instruct the nurse to place her 
nt*ar the edge of the right side of the lied, that the ri^ht hand 
may lie conveniently u^d. The phyaiciau bo b« uotiiitMl when 
she is ready. 

PoBiTiov OF THE WoMAN. — Ou the back, with the kneea 
flexed, is the obstetric position most commou in the United 
Htates. Some practitioners prefer the English |x>sitiou, the 
woman tying on the leR side near the right edge of the bed, 
with her knees drawn up. 

Introduction of the Fingers, — After proper disinfection 
(see pp. 213. 214), anoint the right index finger with carliol- 
izeil vaseline (or mollin), |>er ceuL, or some other aseptic 
lubricant. Fold it toward the palm, and with the thumb and 
middle finger shield it from grea^iing the hed-clothing (which 
must lie previously looi^ened or untucked) while reacldug the 
vulva. PaAs the hand under — never over — the thigh, the 
knees haviug been previously Hexed; separate the labia, and 
introduce finger rather toward jK)s*terior than anterior commis- 
sure, with care U* avoid inverting any hiiir. The index-finger 
will reach higher in the vagina it' ihe remaining fingers are 
(not doubloii into the palm, but) stretched out over the i>eri- 
neum hi that the |»08terior commissure fits into the deej>esl {>art 
of the space l>etween the index and middle fingers. The peri- 
neum may thus be pushe<l in, or lifteil somewhat upwanl and 
inward, when there is any difficulty in reaching the os uteri. 
Id case the index finger will then not reach far enough, it and 
the middle finger may both be introduced together. 

PirRr<«K8 OF Vaginal Examination. — By thia examina- 
UoD we learn : 

1. The c^mditiuu of the vagina and vaginal *>ritice as regards 
their pat«ucy and freedom from obstruction to the passage 



PURPOSES OF VAaiSAL KXAMISATlOy. 



225 



9f the child ; als** their temperature, sensibility (frt^eilom from 
leuderiie&f ). and iiioiiiUjre, 

2. Corn)lM>rutioii of the exL'*leuce of pregtmncv it' not pre- 
viously as'ertaiued hy physioal proof. 

3. Condition of the os uteri — its detjree of dilatation^ thick- 
nvm, ci»nsit*teiicy» nnd ela>;t icily. 

4. If labor have nctually begun. 

5. To wtmt stase it hits pro^'ressed. 

6. Whether tiie bag of waters baa rujrtured. 

7. What tlie presentation is. 

H. The condition of the jx^Ivis, whether normal or de- 
formed. 

\). The state of Idadder and rectum aa to distention with 
their respective content*. 

When aceuMtorned, by practice, to the examiuntion of fior- 
m*il vagina^ pelves, elc, the existence of any fthnonnnltty 
is rea<li!y appreciated by the finger without any |Mirlicular 
attention beinjij given to each of the details just enumerated. 
Ill conuneiicinjj: practice, much more care ia necej*:iry to 
avoid overlooking existing departures from the natural 
Htate. 

In learning the degree to which the oe uteri is dilntetl, it \a 
the «ize of the nrcviar rim (or liiwj of ih<i exitinal oa that wo 
wish to (tfoertnin. Without care the finger may be [»a>«ed 
through a trinaU na uttri and swept round a considerable sur- 
face* of the pn'senting part or amniotic sac, thus conveying an 
impr(<8sion that ttie os is dibited when it ia not. Finding a 
small, hard, easily movable titerus, per rarfinnni^ at oneo neg- 
atives the existence of advance*] pregnancy, unlen* it should 
Impix'O to l>e an extra-uterine cast!. A pregnant woman may 
imagine herself in labor when ehe is not, owing to the occur- 
rence of *\f*.tise paing.'* Theee, on vaginal examination, are 
fouutl to be iniaccompHuieil with dilatation of the os and 
cervix uteri ; they prodvirc no tension or prominence of the 
bag of waters ; nor are they prece4ied with (he premonitory 
B>nnptoin« of lalK)r ; they are irregular in their ocrurremv, 
and do not increase in severity or frequency like true pains. 
Falrie pains pnMluct' inieasiness in the abdnmoD ; early true 
ones ext«-nd to the linnbar and sacral regions. False [mins 
are gcncrrdly priMluciHl by some source e»f irritnliiin in the 
intrstinn) canal, and are usually relieved hy a laxative, aa 



226 



LABOR. 



Opiate 1>einf; juiven nfier its a<lion. The Hinguoeis of a Lead 
prftwiitHlJon limy Ito iiiaHe out even before llie os is dilnted. 
Tlie liMpl. ?rii(H»tli >:lolie ol' the heiul may \ie recopuizeil 
thruutrh the wall of the uterine eervix. There is nothing else 
like it. Generally the oh will iKlinit u tinker, when the craniiiiti, 
if not too high up, may l)e readily felt, covereil hy the mem- 
braues. It is not always easy to Hseerlain whetiier the mein- 
bniues have ruptured. Statements of woman or nurse are nut 
reliable. If there l»p a layer of licpior jinniii Itctween the 
beatl and iticnibninei^, the space and Huid may be readily 
reeoijniw'd by j.fent]e ]>re.ssure with finder behrern Ihe pain\ 
Not so when the rneTnbnuie>i cloj*ely endirnee the bead. Tlieu 
feeling the child's linir, and corru^'ati<»n of the scalp dnrinp a 
pain, phow the bii^ iian liroken. The membrnnes on the eon- 
Irary, l>econie sntoolb and tense during; a (tain, poesibly 
wrinkled a little in the inti^rvala. 

Opinion as to Ti^k of Dki.ivery. — After one examina- 
tion only, no opinion a.s (o the duration of lalM>r ean be eon- 
fideiilly formed, rertainly none shouhl be expre?.*e<l. Having 
felt the head, we may say "everything U ri^hl," and encour- 
a^'e the woman not to de8p*>nii. AtWr a second examination 
in twenty or thirty minvites, we may J'oi'm, but should not 
express, an approximate idea as to time of deliver^-, by 
degree (if any) of progressive dilatation that may have taken 
place, 

Ib it NKTKfiSARY TO KeEP THE PATIENT IN BeII DURING 

THF. First Stack? — No. T^-t her sit, vnlk, or chanfie her 
]wsition as she desires, until (lie bag of waters is about to 
break, when recumbency is (k>irable to prevent wnsliiii)! ilowu 
of (lie umbilical cord by the gush of liquor amnii, and for 
other reasons. 



Rupture of tfte Bag of Waters. — Just hefore rupture 
the woman should 1m? told what is poing to hapf>en, to prevent 
alarm, cfi|M*cirtlly if she be a jirindpara. and an extra cloth or 
piece of blanket may Ije placed under her. lo soak up the Imlk 
f)f the flow. Jusl uftrr rujitnre a vaginal txaminalion sliould 
Ik* made In iiscerUiin more surely the pres**ntalioti, and that 
DO change had titkcu place in it, and the sutures an<l fouta- 




THE rERlSEVM, 



227 



nelles may now be felt, nml the " ixnaitlnn " ' r)f the head made 
ouL The extra cl<»tli may l>e removed at once, 

NtrMDEK OF AtteniiAXTs. — It i:^ iM»t d*?sirHhk' for the pliy- 
Hciaii to remain in the lyiup-iii room durinjif the tin*l stajr* of 
liilxir. At\er huviii;^ wen that every preimruliuii liiu^ i)een 
niade^ aud huvinj; expresstMl a williii;riie»i to lie enllwl at any 
time the woniau mny deflire, k't liim retin; to some oilier apart- 
ment, t^ne nurw it* ueeesMiry, and an ndditiomil aitiMidiuit or 
relative not ohjeetionable, hut ni) ollu-n*. The Imshund may 
be present or not, \i» the wife may pn-ter. 

pRECAiTTioxs HURiNo Early Staor. — If the reetum he 

lou(Ui|, admini»'ter tin euenni of soap and wwWv to empty it. 
See tliat the bladder empties itself. If mtt, use a eatheter. 
Protect the female from a /j^lare oi liulit. whether hy day or 
nij^ht. Keep the tem|>erature of the room at H'*" <tr 70* F., 
if praeticalde. Ihntruet the piitient iiai to strain or Injar dowu 
during tirst stage ; it doe« no good, and tires her, 

PiXniINU OF TIIK AXTICRIOR ^AV OF TI[E <)s TtKRI. As 

the head prttwes out of tltc utxTUS into tlie va;rina the h^wer 
nmrjrin of the lw uteri flifis u]> out of rcarh of the finpor, but 
84tnietimes the anterior lip of the os getH pim>heil 1>etween the 
chihfs head and pubie Ume^ so that it (*annot. slip \\\\. It 
may (lieu lwc<»me ^xreatly sw4»Ilen, (Mn^reHled, and uileniatous. 

Ti't'ot tiff 111, — Push it up with the emlia of two (injjors. l>et\veen 
the |»aiii.s ainl liokl it tht're till tlm next pain forces tho head 
Mow it. 

Cramp in this Tnicdis. — Painful eram]« alonj^ the inner 

pide of the thij^hs may o<x'ur from presr*Mre of the head — 
probably uimui the oliturator nerve, or U|xin the saeral m^rves 
— while passinjr through the i>elvic emiai. 

Tretii III flit, — Kmpty the Iwjwel hy an enema; UJ*e manunl 
frielion u|xm the painful part; and hapten delivery by forceps, 
if neeofeary. 

TliG Phrixepm will usually rei]uire attention to prevent 

* *' l*<HiIlion," In nlmli-ti'lc*!, itii-nn*> i)i>- iHxtUlntiJil nlntUm i-sf»tliiir lH<>tivi*fTO 
avlvi-n (Mitiil on lliir prt'Si'tiiliiLi ixirt ntnl rfrinlii tli«'<l txilntM m|i ih<< iM>lvlm 
TlifTn nn* avverHl " |iuslllunii t«t vtclt " prtwulollun/ u will b« vxplaluvd 
beiraftttr. 



228 



LABOR. 



rtiptiire. There is no fear of laceration 
iHinlcr of it niiiintainn any consideni 
y ou the slrclch tiuring thf jmin^ 



(lo lonp a« the ante- 



rmr 



hie lltii-ki 



jio.'^i nnii IS 
not fully ou the slrt'tch (luring tlie jminK Hence, uo "snp- 
|^M>rt " i^ ucoeftitiry, autl uDtliin^ i.H re<[uiretl hut to watch the 
projrre.*« of i\w liciul [tiow (^iL^ily tnuehtHl iiit'ide the vulva), 
mul iuiwerlain wlien tlie peritienm iUu;^ Wvome thin and tightly 
ilrunii out over the udvuneinjr head, and when there m dauger 
of laceration, esfittcially if the hihor proj^nsss rapidly. 

Trefitmrnt. — Ar^k the woman to refrain from liearinjr down, 
fnmi hohlin;; her brentli, pullinfr with her hnti<l», pushing with 
her feel ;n»d knees, etc. If niial)le loei>utru! her slrainin^, an.TS- 
ihetixe litr. The wtihoda of nuinipuhitton lo j>revent libera- 
tion of the ]>erineuni nre ahnost ((kj numerous and varied to 
meniiou, hut ihi^ principUn involved (which it i» moet impor- 
tant to understand) are few. and always the same, viz. : 1. 
Give tile |H»rineum time lo streteh, hy retnrdinjr expuhsioti of 
ihe heail — e8|>eeial)y hy retarding '' cJ-U-rmoii,'^ 2. Uuide 
the head so ihwt it may weupy iis lillJe spare na )H)rwihle, by 
keepiii^^ the ])hine of itj< pmalhtst i-ircnmCerenee |»arallel with 
the |i]aiie of the jierineal ring thrnu;:h whieh it must |>ai« ; 
or, what is the same thinir, keep the Innir diameter of the head 
at right angles to the plane i>f tht* perineal girdle: the eeutnil 
point of the o<riput must lend — go fin*t — and keep in the 
centre of the ring. 8. Kelax the |>erineum aa much Oi* pos- 
sible by g:ithering in tether from surrounding tissues — "give 
it rope" fn)m the outside. 

The raani|julation may l»e aceorapliahed either with the 
woman upon her left mle, or in the dontat [Mwsilion, provided 
the lower limhs he not foreibly tlexed or widely aeparated, 
aud for wliieh there is no neresnly. Unrewir^ed ocuUr in- 
(tprciimi of the jiarta is al)9ohiteIy rwjuired. Note es|)erially 
that rupture usually o<;eurs at the motnrnt or durintj the few 
ViommiJi of thr la^tt tnie or two jHiittA, just as the head is l>eiug 
extrudeil. Noruiully the head '\» delivered by "extension" 
(see Mechanism of Labor, Chap. XIV. )» the occiput riaing 
over the mons vpuerii*, while forehead, fac*e, and chin sutree**- 
sively emerge at ihr |»-rineal margin. Hence, to retard espul- 
HMu ( whieh may he iloiie dirt'Hhf Uy prer^sure ujMin the central 
tK'ei[jut », w« muirt retard ejicimioii by pressure transmittivi 
through the perineum u|M»n the fronlal Iwaie Ohe Ihreheiid), 
wbiuh indircct/tf retards expulsion. Extension mnd oeeur 



Tin: picmyEi'.}^ 



229 



eventually or the child could not well ho horn : our purjiose 
is to tifiay — i»ot [irevi'ut — il. Wlifii ihe |M^riueui[i ha.s had 
tiiue to .Mtretch, we |Krrniil exteu»iun luid iH)UHequeiit expulniou 
to tAke jda<-e. 

lu the niiiiiipulatiim lo ciirr)' out ihes^i' j>ur|Hiscft, hoth hands 
are 8iniullam'ou.sly used (the wnniun luiiijr either upon her 
side or hack — prefenihly the IbrMitT), iis liiljows: '\hv ritrht 
band is w placed that its tinker? rt^t ujmhi the posterior part 
of the leit labium pndendi. and tlie thiimli upon the ri^ht 
lahiuni, the web of skin hftween the tliunilt and index iiii^'er 
being al)out in line with the iwrineid margin. The lell hand 
!£ paj^t^d down over the abdomen and niona veneris until its 
fiDger-ti]>9 eonie in contact with the occiput just l>ejrinniiig to 
protmde between the lal)ia. During the pains the fingers of 
the lell hand make direct pressure upon the advancing occi- 
put in line with the long diameter of the head, lo stop it from 
coming out, while tlie fingers antl tliumb of the right hand 
gather in ])erineal tissiies from the sides, thnw relaxing central 
tension, while at the same time they — aid(Ml by the palm and 
ulnar border of the hand — traiiismit a deeper pressure through 
the perineum upon the forehead, to rttttrd tjimsinu ; mean- 
while the maui)}ulation ui>avoidably |iushes the entire head 
up toward the piibeg, thus utili/Jng any s|)are space left be- 
tween the pubic arch and back of the child's neck. During 
these |>njceeding8 the parts should be swabbed occasionally 
with a hot (wdution of bichloride or a ple<lget of aseptic cutton, 
and the bandit of the operator wasJiiil in a similar fluid. 
When it is finally deemed advis;ihle (o alhtw the head to 
esca)re, let this occur, if po»#ible. brhrrm the paiuH. 

Other niethcxls of nuiuipuhition — the objects and principles 
of which will be the same as already dcHTibc<l — are the follow- 
ing: (1) Place tlie thumb ujHm the advancing occipiut and two 
fingerstof the sanu' hand) iu the r*'Hnni, by which the fiirehead 
is kept from extension and the |>erineuni rehixe<| by titling it up 
towani pubes during the pains ((.lotKlell) ; {"2} Btanding behind 
the woman ( while she lich UjKin her lell side ) apply two fuigers 
of the right hand to (he (x'ciput and pnsf^ the tbundi into the 
rectum, and thus hold back tlu- head during |uiins (p'nsbeu- 
der) ; (15) pla*v the thund» and imh-x finger or* ea<h side of 
the j>erineuni and gently push it forward and upwanl during 
pains, whiie expulaion in retarded by direct pree&ure upon the 



230 



LABOR, 



occiput (Playfair). To gel uut the head between the pains, 
upward aud forward pressure nuiy \^ made wilh the thumb 
or fingera iii the nHlurii, n|H>u the face or chin ; or prejMure 
upi/n the ouUide^ behind the anus, cUwe to the coccyx, may be 
made ii[K>n the fore.hend, provided it have deseended low 
enough tor thLs purpoHe : thus the hea4l is forowl forward aud 
out over the ptdxtt, iK'tweeii the pains, at the will of the 
operator, lu forceps cases the head may be forcibly reatraiued, 

FIO. 91. 




Mode ofefll-cting relaxation of perineum, f Aftor Pi-AvrAix.) 



guided, aud admitted to paae at >nll, by the actiou of the 
instrument 

Tlie rectal niani)>uIatioiiH — at lietjt iuconaisteut with rigid 
antiseiwisi — requin* extreme oleaiilinefie. 

In cai^es where^ (h>H|tite tht-;^ mauipuhitions. rupture ajtixmrs 
inevitable, the o|)eratioti i>f fjamditnnj may he pL'rfoniK**!. The 
resisting ring of tissue being reeognixe*! by the finger jiuit 
iuside the fwrineal margin, a probe-|K>inted curved bistoury, 
or tenotomy kuife, iH p;b«e4l in ibitwis*- iietw.'ti llie head and 
vagiual wall, at a ]>oiul about oue-lliird of the diiitaucu} Ixom 



BIRTH OF THE HEAD, 



231 



the posterior commisaurc to the i-litoris ; then the edpe of the 
kiiil'e in turned oulwarcl towanl the vagiunl wall, auil na 
\ufmtn\ iiiftilfc altont half to one inch loii;^' and oiie-fonrlh of 
au iueh deep. Thenkiu iniiy or lutiy uot be cut by the iiieision. 
The liirrriion of the rut (when the pnrti*, of course, are tWs- 
tender J I uhoiihl lie *Mip and down" — thtit i.s [uirallel willi the 
long axin of the woniinrn body. It tiiay be doue on both 
aidea. After Ud)or tlie wounds are ytitclieil up with fine UMej)- 
tie catgut- It in not ot^en resorted to» and its allege*! extraor- 
dinary poo*] ri^ultH are not alwayfl realizwi. 

Hhuuld the [wrineum ese4i|)e rupture during delivery of the 
head, it may yet Im* torn during th«^ pi\ss«ge of the nhoutdtrs. 
Thin may he prevente^l by lifting the head and neck up toward 
the mons veneris, »» that one stbouhier goes lia<'k behind the 
syniphynis pubis, while the other esea|M.'!8 at the coreyx. This 
enables one shoulder to be born at a time, and pnxluces lej« 
Strain ujvmi die |KTineuni than when bnth are ]tuUed out 
together, and with rude luwte, which must be uvoidetl. 

BiKTii t)V TiiK Head. — When the head in expi'lh**!, f^nd 
with the finger if the unihilicjil cord cucinde the child's neck. 
If H(», draw down the c^>rd fH»m whichever direction it will 
niottt freely (.rime, mid pnr^ the inop of it thus fomietl over 
the heail. 8t»e that nothing ini^x*<hf* the further free motion 
of the head. Kee]i one hand on the womb, and, by gentle 
pressure follow down its decreasing sizi', tv.* act to Mwist it* wn- 
traetion and prevent hemtirrhage. Snp[K»rt the head in the 
other hand, ami, at* another jwun or two exjxdK the shouhlen* 
and lM>dy, gently lift it in a dirntion continuous with the axis 
of the |»elvic curve — li. c, slirfhthf ufiwtird. No traction is 
m»ee*warv generally ; and though the child's fat-c begin to gel 
hbiir^h. there is no nwtsvity for haste, nor fear of suflm-ation, 
even though delayeil wvenil minutes, which it rarely will be, 
before eompU'te expidsion. -Ij7'*r frpuixion «/ (hf rfitltl. cleiinAe 
its nostrilsi and mouth frotn mucus, vU\, and see that it 
breathe**. If it do not, slap the butt^M-ks (tiot ntughly). rub 
the bpine. dash a little water in the face«>r on the chest, which 
will generally sutfiee in an ordinary case. When ^e^pira(ion 
in established, let the infant rest on the IhhI la^twiHMi (he Ihiglis 
of the mother, prefenibly on its right side or hack, avoiding 
ooutact with discharges, while the imv4>l mring \s aitendcil to. 




LABOB, 

No hsHte is aepetssary iu tyin^ suil cutting the cord, uuleas 

n'hixulioii of the uUtus, flrHMliuii, or some olLier t'outlUioii of 
tbf luuthcr, rtMjuiro iniiiiwliuti' attention from the pliy«i(.'ian. 

In ihi* nbi^ence of any such emergency, it is Ik-sI to wait 
until |>ulsation in th*^ ror*! lias ceascfl or l)ecome almost iinper- 
oeptible. 

Managkmknt of the Navel String. — Ligatures — pre- 
ferahly of utrong aseptic silk (but narrow ta]>e or any other 
suitable material, properly steriliz**<l. will answer), shniih! have 
bt'en previously prepared. When the child has crie<J — thug 
iiiliating ita lungH with air, and starting complete pulmonary 
circulation — the cpiantity of blood thus drawn from its general 
cin^ulation l»eing renewed from the fatal half of the )>Iaceuta 
through the thus-far unolintructed uinbiliral vein — the cord 
nhouhl be cut before ligation about an in^-h ilistaiU from the 
nbdiHiifn. its root Inking pincht'd willi ji (bunib and tiiigercloac 
to the umbilicus to prevent bleeding, while a Knger and tliumb 
of the other hfiiid rvpieeze out of its di-Slal extremity by a sort 
of milking proceas ("stripping") any excess <if Wharton's 
jelly. The stump of the cord (s^'jnictimes thick and volumin- 
ous) thus bec^mies flatvid and riblHiii-likc, when the ligature ih 
put on near its distul end. and tied tightly, but not so tight 
tin to wound the blo<Mlvc«.sels. i**lit)ulii the cud bUn-d, put on a 
second ligature jhhI above the first one and tie it more strongly. 
Dr. A. C Kellogg of Wisconsin has devised an instrument for 
passing over the end of tlie funis a stretched rubber ring (see 
rig. 92). which, wlu-n the instrument is remove*!, contracts 
down on a cvrd. like a ligature, to j>revent hemorrhage. It is 
eHective enough, but not lielter than simple ligation, for which 
no instrument is necessary. 

To prevent injuring the child while cutting the cord with 
ordinary 8(!issors — which might huppoii from the nir)tions of its 
lower lindis iluring Ow o|ji^ratioii^ — place the back of the left 
hand llat UjKm the nlidomen and iH the «*ord project between 
the |>almur surface of two fingL'i*s, vlule thescisHorH oreopplied 
flat-wise with the right hand. 

There is no nect^sity for putting a ligature njv>n the pla- 
cental enil of the cord, unli'ss tuins be snK|H.'cted, when it 
should be d(me. 

The custom of leaviug the slump of the funis one or two 



MANAGEMKXr OF TUE NA VKL STniXd. 



233 



inches long was juIopttMl to prevmt i;;n(tninl [mtsous fVcvm 
iuclu<ling the (nnl uiiroitiiiioi; ) |)rf)lni^iitiu' ^'tit (ff an uri>l>t)i(:ul 
hernia in the liijiUiiri'. When wruiin iliat nomirh htTuia cx- 
ist8« tiie Htwinji nii^ht ju:^l iw well iw (.'Ul till halt' an inrh from 
tiie skin : duch a pniotice hns tteen recmitly rectoninieuded in 
the Latercitt of antiM5|Miri — it leiivcti It*:*} deml liEjt^uetf to ijejiuratc 
Still more recently, the con\ liiw l»et;u cut close to the ahilomen 
and its vessels ligateil separutt^ly JW in a Hur^ical tijx^rution — a 
complicated proc«S8 quite uncalled for ami not to In; rccom- 
memle<]. 

Ailer tumple ligaliuo, as fir»t above-meutiouod, it in of priiue 



FlO. 92. 




EUstlc funlf ririK applinttor. 

importance to prevent infection of the ntiimp, hy <irof\?ino: it 
every day with a frt^h pie^-e of dry ai^cptic (l>*>rate(l» or wili- 
cylated) cotton, the t<ium|> ii»elf, ami navel, having l>een firat 
dustcil over with l>onu*ic acid. 

The cord having been atteDde<] to. examine the child for 
deformities or inalforniatious ; pive it to the nnr»c% who holdn 
a warm Hannel or blanket for its reception ; antl eaulion her 
to let no strong litrht plare in its face, and to jret no soap in \tA 
eyee, Un<ler circunwtjincea and phu-es ia which the ehihl is 
expoHcd to the inferiion of opbthuliiiia nconatortini. the eyelidii 
should l)c carefully wiwhed externally with eletui warm wnt*r, 
and, from the eud of a glai^H rod oue drop of a nitrate of ailver 



234 



LABOR. 



solutiou (streu^tli 1 : 5(1) shouM he 4lrop[>ed on the cornea 
each eye imniediaU'Iy after hirth. 

Dklivkry of Tiiii l*LAt:K.NTA. — Tli^ cliild liaving been 
iliH(n*ftt*tI of, pUfie a liiiiul uikjii the t'liuduri uteri. If it be 
fuuuil Hvnunetricu] m shujie, un<l lUf Bmnll in flize nB a cricket 
hall, the |>hK't'tiUi is pnthahly resting; Iouhc in the vnpiiia. If 
it ho Jarjrer tliaii thin, iirii) nol .-wi HyTiimctri<iilly L'lohulnr in 
shapf*, the |)ln<-eiita is ttM)st likvly *ilill in tlit* wotiili. or lialf in 
UMii half uiit. Ill this liuu*r ciist' inanijiulatc live tumlua and 
m.ike prcsssJure ajK>u it to fxriiv t-Diilrartion. MK'uuvvhile asking 
the wiHiian ti> ln-ar <lowr» when nhe Ctrls llu' pHin luifin. 
Shunhl l\w. |ihi<;enta not hrpx|iellp<i in 1') nr 20 niinutfs Hpon- 
tarn'ously. the fuiuhitt ultri may l>e grasiKjiJ tinnly hy the Imiul, 
and the phutnitn liUTally p«|iieeWNi Jnmi the uterus intu the 
vagina atier the niethoct of ( VetU*. (See Fig. 1)3.) 

Fio. &3. 



'^ 



SEpNMlnn r>r the placenta. (Crbdk.) 

To l>c suoi'cflsful in ihiii iiiaiui'uvro, tlic nterns miiPt lie 
gra*»|H'd IxHlily l)y the thumb and hn;:i'r« w> tliat the fnntlus 
n-Kts in the palm, and lirni prt-Mstire madt' onlv ihtriutj iilfrhie 
couiravtiofi — ^nt the hvifjhl of a hthur pain. tUtth luuids uiay be 



DELIVERY OF THE PLACENTA. 



235 



use*], the eight (liigi»rrt .iroiuj^^ Itt-hind thu vitcnii*, th4' tliiniil«* "m 
fnmt. Hiihl the womb t'oiitiiMKumly, but U^sh lirjiily Itt-l-wt'cii 
the pains, mid rcvuiiie strong pressure i\a the puin returrit^, and 
8t> on for six or s**ven piiiiis if mrtrssiiry — the dircHion of pres- 
sure Uaug ilownwurii urn! luickward in line with axis of uterus. 
When the pliuvnta htis passed entirely through the m uteri 
into the vugiim. it i;* ejiHiIy extraeted liy hwking into it one or 
two fingers and making trnetioii. When it is ordy half-way 
lhn)ugli the oh, the in(U*x and miihile HngerK tire ])atuH*d up to 

Via. 94. 




Faulty aitiihod of rcmoriiiK pl«ccnu by tracUDn on the cord. (Alter 

I'LAWAIH.) 

It folUiwing the conl for h f;uide, nnd tlie organ heing graKped 
between the tinger-end**, i! is made to hnlge eoriiplctely thnuigh 
the oa hy direeting traction futthrani toward ihe HiUTum. the 
other liaiid eompruwing the fundus, atid the wtiman lieing tohl 
to liear down. Never, unth^r any eireumeiaineeH. mnkc traction 
ou the eord. It tenda t« pull the phieenta Halwise (like a 
]mt1<m in a Imllnn-hole^. ihim oliHtrtniiiig its egress (we I'ig. 
94 J, and might, if the plaeentu were Htill adherent, invert the 



236 



LABOR. 



womb. AVlieri unJiaturhetl bv tractioa on the cord, the pla- 
centa will he folded vertu-ally, iu Hue with the loDg axis of the 
womb, OB uhurtii Im Fig. 95. 



Klii. BS. 




Nunnnl doubling of plAccnla. (After DUNrAit.} 

normal cn.sfs it may Im? ix)f»8ible to deliver the aecunrlines 
by uxterniil prw<s*iire alone, an<l without usinp a finder in the 
vagina, nml in tlie line of rv/\i\ unti^HcpetiH thi.** i.t ailvisable. 
It is not nwfssury to hurry the delivery of the plarenta imme- 
diately after the infant's birth: an interval of fifteen or 
twenty minutes drives time for con^uhi to form in the months 
of the uterine liloodvesselA, and thui< eoutribute8 to prevent 
hemorrhn)::e. The practice of giving frffot to ex|>edite expul- 
sion of the plftcentii hnn been ulmndoneil. It may. however, 
l>e jjiven, and with advanta^'e. to secure iirm uterine contrac- 
tion, aft^er the placenta iw esiielle*! ; the d<ise being jsa to 3J of 
the fluid extract. 

As soon :is the orfraii luis |msfted the vulvar orifice, hold it 



THE BINDEK 



237 



there* close U[>, ami with both hiuxU twi.st it roiint] aud round, 
alwax-s in one tHrcMrlion, nn<l the nieinhninc^ will thiin be twisttnl 
into a *f>rt of roj)e, which gTHdimlly gets loujrer and imrmwer 
until terininntin^ In a mere string, whioh finully slijie from 
the vagina, and delivery in eoniplete. li* thif lwir*liu>r devire 
be n<rt tulopte<l a |>art of tiie inendtrane is likely to remain, 
and, biK'oniiug eutun^^led with clutii of liloud, entise uik'r-|mius, 
au<l eomc away, fetid, days afterward, not without ahirm to 
llie [latient 

After delivery the jihu'euta sh<»ulil be insjueted to see that 
no part ba^ been turn otT and leR 1>ehind. and then de^KJHited 
in the veiW?l held by the nurse for iti* reeeptioii. 

Firm coufniction and rrtntrtiott ' of the litems havinjr been 
secured, the third stajje of lalH»r is over. It remains to make 
the woman aseptically clean and eoinforlable. The soilwl 
sheets and pads are n»moved ; the nurse elennse? the skin fnmi 
lihMMl-ijitjiins with a biehloride wlmion. dries it with a elean 
towel ; puts under the hijw a eleau, dry draw-««heet, and the 
{mtient ii* now ready for the binder and vulvar drewinp 

A mild bichloride polution ( 1 : 4*K)0) should Iw used to wash 
out the vagina before the dry dresfiiniirs are applied. It is not 
necessary or desirable to wa«h out the uterus in a normal case. 

Ttte Bixnr.R is an nlwlominnl bandage desijrncd to support 
the stretche^l walls of the abdomcti and eoinprew the uterus 
»> as to prevent its relaxalioti and fvmsequent hemorrhajre. 
It gives' the woman comfort, an*! prevents yyncofK:. It M-arc^dy 
improvi-s her fi^rure iw was onee supfK)!»ed. 

It may \w. mn<h^ of stmnrj unbleached cotton or jean, and 
inust be wide enouph to reach from hffow the projfciintj fro- 
chanters CntherwiHe it will nlip up) nearly to the ensiform car- 
tilage, and long enoufjh to ^lo (»nee around the Inxly and 
overlap enough for faateuinp wnlh strong *' safety-pins." Let 
there ht* no crea-sen under the back. F'in it, from alK)ve down- 
wani, where the ends meet in front of the abtlomen, a» tight 
ns may Iw comfortable. S<mie prefer to (»in it from Indow 
upward. 

Another methrni of applying the binder is to pin it at firet 

' The rtlrtfereiicc bctwp«n " rontri\tiitm" and "rftrartion" Is u folIowB: Con- 
trnrtfon in nn nrtlvr hut trnmtletit iini>iciilnr nrtlnn tii«tlnK only a minute nr«n: 
rCfnurUnn !> Um iM-riinini-iil iiminti'Ujiiti-«- 1>( Iho nriiiiu-M |knMliic<*(l l>y C'ltitnw 
tioo. anct Uiu coiitmctlun ilMzU tins cviuicd. 



238 



LABOR, 



loow'ly witli onlinnry pins put in transverwly half an inch 
apiirt iilonu \\w ineiliiii) liiu', uutl uthTward tighten it around 
the narro>vtr part of tlic wuisl. by puln'ring in u fyhl on each 
side of th(^ brxly, tlu'Hf foliiH l>eiiig retained in |»lace by snfely- 
pin8 Ion<ritu(tinally ujipliod. 

An iisfplir puil f prureriibly made of storilizeil jute or ab- 
»orlK*nt ojtion, wrait|>t^l in cbeese-cloth^, two inches thick, 
four im'lics wide, and u-n iiiolie's lonj;, in applied lo tho hiliia 
to retvive the hx-hial diKluirpe. In the abfieDce of such a 
|m<l a [lerfertly clean, ji^<.*plir napkin Tnay W use<]. Thev are 
kept in place by In-ing faisU'ned to the hinder above and IkIow. 
The j.»ads are to be removeii iiud burue<l as often u^ may be 
Deceawiry from the amount ol" diwhar^v, 

A more peHW-l antiseptic nielho<i — the so-called "rK-dusion 
dressing" — is iho following : A piecT of lint, 12 xS inchcjt in 
size U soaked in and wnin^f out of a 1 : 20(H) birldoride «)lu- 
tion. It i.s foldt'd in the nnddle lenjrtlnvi.se, and then folded 
again, wliicli rnakey it three iucluH\side and tour layers thick. 
Thi.M is ftp])lied directly to the vuha. Over it is placed a 
pi(HH» of aseptirnlly clcnii oilc*! silk or mnKlin. four inches wide 
and nine inchcss long. Again over tbi?i coniett a large pad of 
cotton-batting, the whole being kept in jOace by a tK^uare 
half-yani of nnislin, foldwl like a cravat, each end <if which 
\» fn^kMied to the abdoniinal binder. Tiie dre**sing Is dianged 
every Mix Imurs. and the external genituls are laved wiib bi- 
chloride solution before a new on<' is put on. 

Before any dressing is npplii-d, the |ierincuni nhould be cx- 
aniin(*il, in a/l vnnrt^ btj ovular hixjifclifjii^ for laceration. If 
any he found it should al once \te repaire<l by sutures of a»e|>- 
lic calgut. Catgut snturea require no removal : they may Ims 
loft to digest in the tlssuefl and come away of iheniyelves, 
The futureti may be pnmted Iveforc the placenta ia delivereil, 
and lieii after its ileliver}'. The |>iirt>t arc less senMtive imme- 
diately after labor, and the aupeRtht«ia produced during deliv- 
ery still remaini*. 



Attentionb to Newborn Child. — The nurse anoints it 
with olive oil, and then wa.shes it with mild soap and water, 
to reni<»ve the verinj rntnoM — an ac<'uniulation of whitish 
ftdiareoUK matter — from the skin. es[»ecially plciilifnl flb<uit 
folds and creases. It is most abundant in over-long pregnancy. 



^H MASAOEMEST OF MOTHER AXO CHILD. 239 1 

DRR!!*8iNr, TITE rtxT^Mr OF Till' t'oRO. — It in an olil rtmlom^ H 
slill pFL-vailiiiK in some rural (liHtrifU. lo dniw the i*tuiiii» of H 
the i'uuis tlm>iigh a liole niadi* in llu> centre of a liit of ^Teiwed ^M 
ra^, then l'ol<l the lioniiTs ot' thu ra^ over, niid after luying it ^M 
upju the ftlKiomeu with the eiA tlownwanl. \*\n<^ one or two H 
l>elly*hun(lA roniul tlie chihl to ke«p it in [ilace. It in an ^M 
alMjminahle pracritv. If there ho no detective tleveh»priit!tit of ^M 
the ahdotiiiitnl wall)*, the infant neeils no artilirliil sit[t{K)rt hy ^M 
helly-haitils (they are often applied painfull)' (i^dii>, iutil the ^M 
eonl itself only retjuirert lu In; duj^ttd with mam.'- antiik'ptic H 
|M>W(ler (rialirylic a*^id nuo [)art. stjin*fi t^-n parlw) ami wrapjHHl H 
in a bit of antiseptic cotton to ahsoih its njoi.nture and preveul H 
sticking; to the clothing. The stiittip falls utl' in attottl tive ilays, ^M 
mure or iem*. A li^'ht Hannel handage ntay surrouud the at>- ^t 
domea looaelij for the sake of warmth. ^^^M 


MANAGEURNT OF MOTHKR AND CHtLn AFTER nKLIVF.RT. ^^H 

The coadition of l>eing in "child-bf^l,** whether during or 
ehortly after parturition, \^ known jus tho " Puer|>eral State*' 
(from "purr," a child, ami "y«inV>." to brinpr forth). The 
term, however, Ls generally rcstrictoil to a jwriod of four or 
tive weeks immeiliately folhwhifj the c<«n detion of InlHir. 
Hence certain dbH>a.*es ffdhtwinj; lalM>r are ca led *' punftrral** 
fever, *' puerjwnt/** |K!rit*)niti8, eU', The woman is 8|>oken of 
as the '' pttt^rpfi'tu* and the condition or ]>eriod as the "puer^ 
periuuiy'* or *' pm'rfjfrafiff/.*' 

The more serioiw puer[M?ral affections — not of frequent 
oc(Mirrenre — will ho reiiorveii for a future chapter. 

At present only the more trivial and common accompani- 
ments of t)nng-in will he considcrc<l. ^^^| 

riKVKRAL Condition OF LvtvciN Womfn. — A mnderate ^^H 
amount of fatiL^ue, exhaustion, and nervous phock follows ^M 
every labor, being more marked in long and painful ones. In ^| 



240 MANAOE^tENT OF MOTHER ASD CHILD, 



normal en^^eti, rest and the mental stitnulns of joy that a child 
L^ horn into th<:; world, and that the trouble is over, afford an 

mletjuaW Hiilidot{% 

The puiiie, atU-r tk*!ivery, dimiuishes lu fre<iuenoy, dropping 
to 70, tiO, i)i), or even lower. A slow pulse is of t'avoralile 
augury — not so a fretjuent oue. This \» explaiue<i as follows : 
the heart, normal ly hy|H'rtrophied to meet the extra circula- 
tory re<juiremeutrt of pregnancy (see page 107), cannot, when 
prejrnancy has eodai, oouiiuue its powerful heats as frefjucutly 
as (K'fore. without sending to the uterus and other orjranft. more 
bloo<l than I hey refjuire, (with coutfe<p)ent congewlioM and 
danjrer of hemi>rrhagej ; nor can the hy[>ertrophied heart 
Bwldtnftf underjro its struoiurftl involution back to the condition 
in which it was i>efore prejjnaiK-y l>egan (this requires time) ; 
the ditticulty is however naturally oven-ome, by the |x>werful 
heart replacing the number of its pulsations. Wheu this re*luc- 
ti*m does uot take place there is dan^^er of bleefiinj;, and hence 
tlie common ol>servation that a pulse friMjuenoyof 100 or more 
per minute, is lial)le to iinwluee [Mtsi-|)artal hemorrhage, under 
which circunistanei-st tlu^ piiysiriau should not lenve his jintieuL 

Owing to a tlitfereiiee of lempt?nitiire between the blood in 
the internal orf;nns and that in the skin, which occurs just 
after the birth of the ehiUl (an<l before the placenta is ex- 
pelled), due to eva|)oratiou of sweat, ex[)Osure of tlie skin, 
and ceMHilion of muscular effortf the woman may l>e seized 
with rigors (chilliness. Irenddinjr. ehalteriujr of the teeth, etc.) 
— the sfM^alled *' jnmt-jntHttm rln'l/.'^ It passes off in a few 
minutes without any ill effeets, under the application of warm 
clothing, and, perhaps, a glass of wine. 

The Lochia — LorniAL Disr-nAROR — It is a discharge 
from the uterus followinjj labor, consisting during the fin>t four 
or five days, chiefly of blood, which has oozed from the pla- 
cental site or l)e<'n stpiee/ed from the placenta itself during its 
expulsion from the uterui*. Dnring the sixth and seventh 
days the h\ocK\ color should disappear and the disM'hargB 
aasume a thinner an<l more senms rharacter, with scarcely any 
color except a slightly yellow or greenish tinge: at this time 
it consists of a serous exutlation from the walls of the uterus 
(chieHyi an«l t»(her parts of the genital ranal. From ihe 
eighth day on until it ceases — varying in diHereut cases fmm 



THE LOCmA-LOCHIAL DISCHARGE. 



241 



two to three or even four wet-k;? — ilie ditKhar;^'e l)en>mes still 
grailually t^iualler in <iimiiLiiy und of a whitish rolur, ihi^ latit 
heiu;: tliie to leucocrte:! and nonnal pus ci.*!!:^ coming from the 
grauulaiing surihre^ of hoaling wminda upon ih© cervix or 
elsewhere. Conformaldy with these ihree vavialions in color, 
the Inchial dis4'hargi% dtirinj,' the ihn-e sutN-e.-.sivc perio<ls, has 
bi^u ealleii, lochia riibra^ hx'hia ^intm, aud lochia a//»a. 

Examined microyoopicnlly, it is seen to cuuiaiii, at first red 
aud wliite l(lotMl-<'orpuyclc», varioub kinds of epilhdiuni cells, 
decitlual and placeiilal debris, etc. After a week [>us cells, 
leuciKTte? ahound, with young cpilheliuni cells, fat-grauuIes, 
cunnective-tiiisue lellti, and crystals of cholesterine ; aleo a 
variety of micro-orgauisnis — the diplococci and streptococci, 
rod-hucteria, the trichomonas voginaliH : sometimes gonococci, 
ami the long ha<-illi of Doderleiu, which last are Bald to pre- 
veut ye|tt*i» hy developing an acid wliich destroys poisonous 
germs. 

Treatment — Antiseptic dressings are applied by the nurse 
for its reception as previously explained (|»age 238). The 
pads rwjuire to Ite chaugw), at first, six or eight times daily. 
After tiiree or four days, three or four daily changes may be 
enough ; all dei>end8 u[wu the amount of discliarge, which 
varicri in different cases. It is usually greater in ihope who 
menstruate freely, in those who do not nuri* their chiUiren, 
and in multi|>ane. The average quantity during the tirst 
eight <hiys in three and a quarter |K>unds ; of this total, nearly 
two antl a (piarter |x>unds are discharged during the tir^t four 
days. The quantity cannot, of course, be meahured : it ciui 
oidy l»e judged by the numl>er of napkins or pails used to 
receive tlie (low. I>ometimes the disi-harge. after hiiving lot^t 
ittf rcil color, will again become blooily. This is usually due 
to getting up too 8o<m aflor delivery. Id such wises put the 
patient to bed again, and if this alone do not restrain the How, 
give ergot three times a day ; or tinct, fer. chlorid. gtl. xx, 
three limes daily; or a hot water (110° F.) vaginal injection 
continued for fifteen n)inut4's. The mtmi ini|K>rtnnl mutter 
with reirard ii> the lochia is the early recognition of any <liR- 
agreeable, really pufrt'Jirrnt txior it may ikkvch^ This calla 
for immediate investigation an»l thorough cleansing of the 
^^vagina and uterus by antiseptic irrigation (we Fueqieral Sofi- 
?iemia, t'hapter XXXIV. ^. The Fmrnia/ odor of the lochia 



242 MAy.ifjKMEM' OF MOTIliCH ASD CHILD, 

is, ID ft way» ilisiHJret'alile, but it is not pulreseenL During 
the tirst few iIhyh llit» iiaturiil wlar ba»» nut iuaptly. l»een c<»m- 
|»are(l U* that of raw meat, while later it K^vhu** of a peculiar 
character tlifficult Ui (iew.'riiK-, hut without uuy reseinhhuice to 
putxidity. 



After-paixb. — Thesteare jwiuful contractions of the uterus 
foIUminj; (ieliverv, for t\v<» or three- — rarely four days. OtU'ii 
caUHwl by retaiDe<l hlood-clott* or nienihniiiw*, owinj^ to uterus 
hiiviag l>eeu inij>erfectly coutraete*! alU'r expulsion of pla- 
ceuttt. SeUioni «*Tur in pnmi[iarie. Are worse in short, inac- 
tive lftl»oni, and in case* where the uteniH haj* been over-fli?- 
tended. The pains are intermittent, ftccoMi|Kiniwl with harden- 
in*: of the uterus, and are not attende*! with risf of pulse or 
temperature, hy which they are dlBtiuguished from jK^lvic |)ain 
due to iuHamtnatioii. 

Trt'tttmrnf, — AfU'r-jwiins may l>e prevented hy seciiriug 
(*oniplete emptying ami firm contraction and retraction of the 
uterus, durinp the third fita^re of lalxtr. To relieve them, pivo 
two mwliciiies, viz.» ertjot, to pruluoe firm contnu'iiou of tlie 
womb and the expulnion of any blood-clot>(, etc., it may con- 
tain ; and an anofiyne to lessen the |muh of these <i>ntractioD8. 
Fid. extr. er^'ot ^sb, with Ir. opii cumph. 5ij, may be ^iven 
every three hours, or er^rot liy the month and a rectal hujv 
|M«itory of nmrphia. Chlonil, 10 jrrains ; Dover's |)owder, 5 
^i*ain8 ; jdiena<*etiti. .'» ^niiiiH, or any oiher anodyne. Ano- 
dyne linimeni.4 and Inn [loidiiccs of ho|>8 applied to the hy|io- 
pu^trium will K^metiniirK atford relief. A laxative enema, llie 
woman sittinir np durinjcr it^ action ('there hein^ no contra- 
indicatiou to this procotnlinj:, from previous hemorrhage or 
weatuieaa\ will olten empty the uterus and secure it8 firm con- 
Iniclion, relieving after-pain.**. Digital removal of clots and 
pii^'es of mendirane hxltred in the <is uteri uniy ixwwibly be 
neccswar}', but this r«|uires the 8tricte!*t antiseptic technif^ttc: 
in mo*it cases erjrot and opium will be nufhcieui. 

When the [wins are due to neuralgia of the ulenw. give 
(pdMia sulphat. gr. v-x. 

They al.st> occur from refiex irritation everj' lime the child 
iw put to the brensL Time and jiaticnce will relieve this. To 
lessen flufl'erin^^ pivc i^otaiw. bromide, gr. xx ; also anodyne 
lininieuto to breaitui. 



THE MOTIIEirS DIET, 



243 



The MothkrV Cciwkus. — Laxatives during tlie first two 
or three days ai\(T labor are not nwtir^iry, if llie bowfla were 
freely o[)eu before tl^'Uvery. II* no acliou uccar spontiineowsly 
by tl»e end of tbe tbird day a sdiiie laxative — citbera Seidlitz 
powder or a doee of nuLju^iieHia cilrali? — may im giveu ; or an 
eueiua eontaininp tme ounce of eiwtor oil in a piut of soap and 
water, to wliich. in ease of tympavitrA, u tejW(Hiouful of spiriliJ 
of iurpentiuc may bo added. If pills are preferred, give two 
or three of the pil. rbei eoni[j., or in caf*e. a more active pur- 
gative 1m? needed, the niucli-*.'oinniended *' pottt-partum pill'* of 
Ih". Fordyce Barker rimy be given, thus: B, Ext, e^jhx'ynth. 
w>-i Bj ; ext. hyoseyiini.. gr. xv ; piilv. aloes »(>c., gr. x ; ext. 
nuc. voiu., gr. v ; |KMiophylliu, ij»eeuc, aa gr. j. M. Ft, pil. 
nu. xii. 8. Take two at onc«. 



The Mothi:r'8 Uuine. — The urine may be wholly or par- 
tially reUiine*! fmm swelliiig of the urethra or want of con- 
traction and loss of seuj^ibility in the bhidder. Relieve by the 
ejitheter three tiincM a day until the partti resume their normal 
function. Ergot internally Hlimuiatc** cyjrtic contraction. Hot 
applicjitions to the pnbcs, or laving the vulva with warm 
water, nuiy utfonl relief. Tiic woman shoubl be reminded, by 
the nurse, to |mi«8 water within eight hours ai\er delivery, 
otherwise the liladder may become overdi«ten<lc<I without the 
patient jK-rceiving it. (.'hange of |Kwture from reeuml)eucy to 
ailting — there Iteing ncn-imtra-indication to it — may enable the 
Woman to pantt urine without a catheter, lit^ may alno 6xing her 
attention u|M>n the souml of water dribbling into a basin. 

When the catheter in use*l it should have lH>en previously 
8uiinKTi:e(i in an atitij*e|itic solution, and the cxterual geidtalia 
should have been cleanse*! antiHeplically to avoid the iutroduo 
tion of vaginal diwhurge into the bladder. The introduction 
fihould Iw done under direction of the eye, not by the touch. 
The labia liaving invn neparated by the fingens the meatus of 
the urethra Is ^r?i, and the instrumeut put in. For rcawnfl 
of delici\cy this may preferably be done by the nurae if she 
the rwpii«ite skill. 

The Mothkk's Diirr. — The "tojuJt-and-tea" starvation 
syHtmn atier delivery is injurious and obi*<)lete. The woman, 
however, re^tuirefi but Utile food during the lirst two or three 



244 ^fAyAGEME^T OF MOTHER ANV CUJLD. 



daya, for the reasonB that she is ubm^rlnng nutriment from 
(uisiit« uf the iiivoltiling uterus — fmm one tx) two pouiHin. loKt 
in weight \>y the uti?ruH. heiug thus tukeu up into iht* hlood, 
UH H4J much (li^esleil ItMMl. Moreover, nutut woukmi tttore up 
fat (luriug pre^iiaucv, which can l>e drawn u)>un u& fuod with- 
out the exjicuditu re of iit'r\'OMH force required in the process 
of digestion. To lessen ti»is e.x|»enditure us far as jHJSsihle, a 
liquiii diet — chietly milk — and soup is Itetttr for the first two 
days, or until the milk K'cretiuu h:iti been estaltlifheil. The 
drain o<»cflHii>neil l>y the ndlk How — utter the thin! day geuer* 
ally — ereatert a want for more fotnl ; hence sott-hoiled eggs* 
fish, potatoes, the hrea«t of chicken, oyfiters, and similar eaaily 
digt*lihlo suhstances may he allowed, at firgt in moderate 
quantity but gradually increased as the imtieut is able to 
digexit them. 

Milk Fever is a transient, slight, febrile excitement, pre- 
eBdc<] by chilliucHH, attending the ef^taltlishmeut of the milk 
tMcretiou. It scart-ely re<juirep treatment, and is far lew fre- 
quent now, than when women were uujjroperly fed, and un- 
protected from t*cptic infection. Ucccnt authorities uilirm that 
**niilk fever" is a mytli. and that it never occurs. This is, 
for the moHt [uirt, true ; the disea^' has been altolishcd by 
proj>er fiH'ding and antiHejftiiH. Under opjwfiite circumstances 
It mayi however, still come on, ai* of old. 

Sore Nipples. — " (tapped Nippffj^." — The apex and sides 
of the nipples are nffiw'tHl with iiKHuret* like a chnppeil li|i. 
There are great [»rtiu and fH)nie bleeding tUiring suckling ; fiain 
on touching nipple ; (issures visible on inspection ; in severe 
cases, fever. The agony of tiuckliiig and c<JH5equent uuvill- 
iugnesB to put the child to the nipple may lend to accumulation 
of milk, foUowe^l by inllannnatiun and ab»cefi» of the breast 

Treabneuf, — Preventive: Caution the woman ogainnt tiattcn* 
ing her nipples by pressure of corsetn, etc. Keejt them a/iit- 
eejiiicuUy dean, for at leant a week before delivery, as well aa 
after labor, between the act** nf puckling, by frwjnent appli- 
catioim of a naturnt*.**! holution of lioric aeiil. The child mu»t 
not i*leep with the nipple in it-^ mouth. After each art of 
nursing cleanse I he nipple with warm water, dry it, and apply 
a light coniprcHt^ vvet vutb but it mid aolutiou. 



EXCESSIVE FLOW OF MILK. 



246 



Curative: Wliileuursiuj^' uee n nipple shieM— one with hard 
base and ruhlwr numth-piere — previoiinly remlerwl ni^plie by 
immersion in Uor'w jiciil sululiou. i'^ju-li (Lsstire iiiuy !h» touched 
twice daily with Holulion uf nrsTfUl. nitras, fjr. xx, to water 
5J, by means ofa vtryfinr oiimerri-liair [K'ncil. Wei the fi.«8ures 
otiltf, not the whole nipple, with the silver Hilution. This 
treatment hy the silver Hiliiti(m, if conjoined with ahdinrnce 
from stickling for twenttf-fottr hoursj is mtwt. etfet^tive, and wiU 
sometimes eure in a single day. 

Other np()linition are: Tannin and gtyceriu, equal pirts; 
nitratiT of lead, kts. x or xx. to vaseline, ^ ; the tr. benzoin 
eo., applies! with a brush, lejxves a film over the erosion ; 
lessens pain an<l promotes heali[i<; ; bismuth subaitrate and 
eastor oil equal parts applie<l freijnently. Many other reme- 
dies have been employed. They must l>e removed, of eoun^e, 
I)ef(tre iIil' child nurses. For slighter and more supertieial 
irritations of the ni|)pU! without uhvra or lissfures, rleainse and 
dry them atler each act of suckling, and dust with jwwdered 
oxide of zinc or jfum arable. Another plan is to keep them 
moistened with a ra^r wet with (Toulard's extrat^t ^ij, to water 
Oj, carefully washing it olf Ix'fore nursing the child. 

SlTNKEy NiPrKfs. — The nipple is too Hat, shorti or stinken 
for the month of the child to gnis|i. The infant attempts to 
nurse, tails, and turns away crying. 

Trrnttiifut — Hold the chiM in rendine."*s while the nipple Is 
first drawn out by the mouth or fingers of an adtdt^ or breiist- 
pump, and then apply it promptly. Another plan : Hold 
over the nipple the mouth of an enij»ty trlass tiottle whose 
contaiiie<l air has been ])revioiisly rarefied by heat, till lh« 
air cfM>ls, and the nipple is drawn up into the neck of the 
bottU'. Then remove it and apply the child imme<liatoly. 
Still another device is to draw out the ni|)ple with tlie fingers 
and »lip an elastic rubl>er ring round the base while thus 
drawn ouL Tlu? ring must only he woni a few minutee, and 
mast not l>e tight enough to strnngulnte the tit«ues. 

ExrrsstvE Flow of Mh.k. — The breasts overflow, or b&. 
come lender, hard, and diHt^mde*! from ncfMimulatiim of milk. 
Danger of inflammation :inil nli.^ci^ss, if n.it relit'ved. 

Tn'ahneni, — Ki^trict llit; woman's diet (aj drv f<MMl, as fiir as 



24r> 



MASAOKMKST OF MOTHER ASH CJJILD. 



|x)wil)If ttltstiiiemv from niiiiLs. I^xiilivfH, prerenibly HnliueH, to 
pro<Juce waterv slools arul rwluce llit* Hiiuls <>(' ilie ltl<Ki<!. Dia- 
phurelics (iiq. ainiiiou. luvtat. 5*" fvery l«x> huUTH) ti» priKluce 
watery secretion from tlit skin. Iv^milly : U. Ext. htllinloiinie 
jy. liniment, eiiniphor. .y. M. ^i^r- Apply to l)rp:Lst.s with jrt'ntle 
friction of the hand. In^-toa(l of tlie IteUmlonna. whtcli i;^ di^ 
a^rewihle and liiil>le in «»nie patients to produ<*<' ditiitntion of 
the pu[iil and other oonslitutional effeet** of the i\xyi\Zy rapid 
reulwirjUion of the milk niiiy he secured hy painting the 
breti>tt^ (nil Imt the nip]>lL'«() with tinct. iiKliiiii. luul uoiupren^ 
iu^ them with cushions of raw cottuii aud a handu^^e. 

Liirj:e dose^^of |>ot4uss. ioilid. {^v, xx thret; limes adayj with 
rigid enft^rrement of dry, nliftcnrmus diet, and nuMleriite, con- 
tinued ('omprc,'«ion of The hrrasl.** with fuilicsive phusier-s will 
soon entirely utop the secretiou of iiiiJk, as may ht; uet:e!swiry 
when the child dies or the mother is not able to nurse. 

Deficient Milk-klow. — When due to anemia, dehility, 
or hemorrha>;t.^ luiihl np the |>aticnl with iron, qniiiiji, hitler 
touio^ and (luthtiouH t'mKl, i«|M.H;ially ii\ilk ; hut of all niilk- 
prtKlucinir fi>ods the m«a*t directly eiticacious id nub^, whether 
wit\- i)r hanl-shclled. Oynten*, r-lams, hdisters, and nearly all 
kindn of nholltish are ali<o pooil, C4ire hein^r taken to avoid any 
which, owin;; lo idiiisyncnisy on the part of the woman, iii^ 
a^ree with her. K moderate amoutil of wine, or preferably 
malt liqiKir — lajjer beer — nhould l»e taken with meals. The 
reputeil g^alactagoj^ue pro|)erty of fimienliUionH to the breaMis 
of leaves of the cast<tr-(H] plmit» a-s well a:* that of the Huid 
extract takeu iultTnally. luu^ lH*en overniteiL The up]flirution 
of electricity has been recently enipUiyed with M>me succt>8 as 
n palactajjot^'ue. One of the lK*st vrgtiahle Ibods is lK>ile(l 
fresh beets, eaten without vinegar. 



Artificial Fkedincj. — If the mother cannot nurse her 
infant, it must l>e nourishe*! by a wet-nur«*. When none can 
be obtained, fjive cow's milk one pjirt fl»y measure) to two 
parts of water and add milk sutrar ."iv to each pint of the 
mixture, the projxtrlion of milk to l^e inerejisiMl with a;;e. 
When this ft^xl disagrees, and the child passes lum|ie of undi- 
gested! cnnl, one-third of the water nuiy Ik^ exchanged for lirao- 
water. Tlie water must l>e eterilizeil by boijiug, ami the milk, 



SVCKUNO THE CUllD. 



247 



not hy boilinp, which ini]ijiirs \t^ mitriiiv<^ value. Init l>v P<w- 
teurUntion — i. e„ hy kve\t'ni^ it roi(tiiiU(tu**Iy tor thirty tiiiiiut«a 
al a It'ijii^rature of' l<i7° F. 

It w of the utvioM ivijxirtanee that nipitlet;. iMHtlt^ and ves- 
seLs iu which the foo<I is preparwl .shouUl he kept asfpticnlly 
cleAD. Tlioy tmist not he unrtl twirt' without hciuf^ tli<trou<rhiv 
oleanw?*! — the hottles and vettfels (wnhloil ami the nijijiU* iin- 
lucniwi ill solution (if (mrir aciil. The hest rule m* to how 
mufh of the niilk-nuxtiiru tfhouhl lie ^iveu the rliihl ot one 
limfy \» to give it as miirh tis it will readily iakt ; if it rejet't 
any. give it leas uext time. 

How LON(i siiom.D rnK Motiikr kkki* iikr Red after 
Labor? — The popular, conventional rule is nine days. It is 
a cuHtom without reaj*on. Some Htron^r. vi^^onjus women with 
healthy and well-contracte*! uteri, nii^ht ^'t^t up HH>ner ; others 
require a Tiuieh loncrer |H'rifM.L Everything ile|>en<i» u|K)n the 
clmracler an<l eoiiiplicalioiiH of the lnlM)r, the gtrenf?th of the 
woman, and the condition of the uteruH. Ton early fretting 
U[», while the wonih in lur^e and heavy, and its natural piij*- 
|K)rt» relaxe<l from the Htretcluug of pre^nanry and labor, 
endanjren* uterine diHplacement>', ctMipefdion, rettirn i»f hhwuly 
lochia, and t^ubin volution. It in tietter to err on the ^afe side, 
hy tuakiug the lying-iu t«x» long, than to risk tiK> enrly rising. 

SurKMNd TIIK Caiu>. — The infant may he )iut to the 
hrea^t as soon as it ip waphed. drcj^icd. and n-ady for the 
mother, provi«ied nhe Ik* not over-tired. If she l»e, let her rest 
a few hours. The child may nurtte alwut every (bur hours, 
dnrinfT the first ihiy or two, before the (low of milk b<»gin8. 
After then, more fre<]uently, every (wd hours, except from 11 
P.M. to 5 A.M., wlum the mother should he allowed continuous 
sleep. When the child is #ix months old, five or six timetii in 
twentv-fonr hours will be suHicicnt. 

The breasts shnnhl be suckled alternately — first one, then 
the other — and the nipples tenderly cleansed with a 4 ]XT 
cent, solution of burux and water l}efore and alter each act of 
nursing. 

The How of milk is not usually eptahlishL'd imtil the i*e(M»nd 
or third day aller delivery. During ihi-si' first days there is, 
however, a little im{)erfectly formed yellowish milk, known na 



243 MA^WOEMEyr OP MOTH EH AND CHILD. 

the **cc>l(mtriini " rstT |>afre (Jo), which is tnoiijj;h for ihc* 
iiifaut witliout the achlition of any nrtiHcial fotnl. nn<l acte 
iip«ni it 113 a laxative to n'movc the •'raeeoninm," or native 
(HMitinits sj{ the inteHliiiul cuaal, i^unsMtiiig of uimliK^rhiMl bile, 
UkucuB, etc. 

Laxatives ix)ii the Ivfant. — If the child's Ixiwels fail 
tj) move Sjwiitanetmsly, wliioh is rare, a little *'i»int'h" of 
browa suiyjar (iift*«>lve«l in a teiu*]»iMijiful of wat^r ruuy hejriveii; 
or half'n tftaspoonful of olive oil, or a little eueiiia of 8oa|> and 
water, or a small nrtal *fu(>i»oeitory of glycerin. Before 
piving any laxative it must be known that the child is not 
Bufleriuj:^ from imjK»rionite anus. If the mother l>e ronyti- 
|iateil, laxutivfc's ^iven to her will reappear in the milk* and 
0|>orat^ on the child. 

The first evanmtiona from the infant nre black in color, 
sli^duiy tinji^od with ^reen ; ihcy h^M^jnic yellow in a few days. 

TnK IvfanVs Ukin'e. — If tijion in<|iiiry the child is re- 
|)orteJ not to have pa.ssefl urine during the first day aiWr 
delivery, examine the urethra and lueatiia for <'<>ntrenital de- 
fomdty ; feel, above the pubcH, whether itn bla<lder 1h^ dis- 
tended, and aiicertaiu that the unne hoA not been voidetl in 
the l»ath miawarea. 

If the bladder l>e fidl. a sprinkle of «>ld water on the hy|x>- 
jrnstriuni, or a warm iMith, may answer. A ver}' t*ninll elaittic 
catheter may. vrnj tan'ly^ Im) re<juirod. 

Most cases of ap[»areiit retention of urine are really due to 
nnn-«c(*relion ; the infant takes but little fixKl, and may excrete 
but little urine. Ijet it aloue. 

Inkantii.k .lAirNrnrE ^Icterus Nennatnrum). A common 
nlTection rlurin^r the first week of infant life. 

St/wptfotvi. — Yellow akin and conjundiva ; hi)j;h-oolorod 
urine; Hj^ht-ctjlored Htiwdn. 

(\tiiJit'K. — Re<*pntly it has been aiu'rilxsl to se|>tic infection 
thrtnijrh the navel. e.«|»ecially in lyin^-in hospital;*. The tijrht 
njiplication of belly-hiunK restricting the respiratory motions 
of the alxloniinal walls and diaplirafrm. ujion which the 
portal circulntion chietiy dejiends i.** probably a factor in the 
production of thf» dipeas". It oivurs more frequently in pre- 



VMBIUCAL HERNIA. 



249 



mature iiifimls ; in Imys titan prls ; in the chihlron of pri- 
iiii^ianL', aiul in cu-stH of nialpreHMitation. 

Treatment. — Nothing? inrtlitr than the removal nf* lielly- 
ItODfia may l>e ne<^L'*j«nry in slijrht vxim^. It wion poea away. 
In severe 04ii»t«, witli tHMiHtiputiiMi, jfive calomel oiie-Kixth of a 
grain, with one prain of white i^nfiar, in |>ow<le.r, ihre*^ tinu^ a 
<hiy, for one or two ilays, tollowed by a tea8|iooul"ul of olive or 
oaHtiir oil. 

In some cufes there is apparent but no real jauudioe. The 
skill in (-oU>re<l. while other symptonid are abeeut It jMuees 
off without treatment 



fioRK Navki- — An ulcer, nau»lly with 8])ronting. iUlihy 
granulations, remains aHer falliuji: off of Htnmp of funis. 
Unually caused by friction and prcst^ure of baniUijLjtes too 
tiglitly appiied ; may also be due to septic iidectitm. 

Ttrotineni. — lieniovo all (Inassinjrs and bandapes. C'U'uuge 
thorouphly with U)nc acid Hohition. Touch tlic granulaiiona 
with |)eucil of arjrent. nit. Thtdv duj^t UHvel with uutiw'plic 
pf)wder of salicylic acid and starch ( 1 : 10) ami cuvcr witli 
nntiseplic cotton. In Konie oiws the funpus fjranulation, ath*r 
cfttiteri74i(ion, fails to di«ip[M>ar : it |x*rsistJ5, bo^ouics s*iliil, and 
perhaps pwliculated like a little jxdypus. The mat« nhiMild 
lie ligat.ed and cut off. 

rMniLicAi. Hernia. — In the eomriwvn form ftf umbilical 
hernia in iniantj* a soil protrusion, al»out the niz<' of n (iuL'cr- 
end, projects at the navel. It l>e<Hm»es more tense and prom- 
inent when the child crie*». It \» eaaily reduced by digital 
pn«»ure. and the finder can then feel the sharp borders of the 
ring through which it came out. 

Treatmf'nt — A round di(*k of wood, a coin, or a button is 
wrapfKMl in lint or HJMie «>R material, and kept in [Kwilion 
(»ver the umbilicus with a li^dit clj)j*ti<- baml.'tj^e or with j*tri|>B 
of adhet^ive plaster, the.se appliances to l>c removed for clenns- 
injr purjtoses* ami replaee<L Recovery wx'ura with >*ul)iH.Mjuenl 
eloBure of the ring. 

A much mon' tterioUMform of undtilical hernia rar/'/y ooeuns 
with iMi|>erfect development of the abdominal wall, in which 
large prutruMon^s of intestine ami other alidominal organs Lake 
place. Theae refpiire a plastic surgicid o|)enttion. 



250 MANAOEMKM OF MOTUEIi AM) VUILD. 

Seconimry Hi:M(JKitiiA<ii: kuom tiii-: rMitiLHiTs. — A 

dangerous mul oHeii t'lilul Ikltrediiig from tlie nuvel, coming on 
diiys, or evt-n wocks, iifh^r di-livcry, and rcinirrinjr (soiiulinu'fl) 
again and apiiii, in s|iite. oi'styittics, li^'ivtiircs, the lutuni cau- 
tery, And uthor menus tfmt must l>o |ir">iii])Hy tried fur its 
relief. The l>est (>h»» iw to t^ln^(ix the hiiwe of the umel with 
two liiirelip fiius, nud julss a lijrure-of-H lijraturc around the 
etids of eiich piiu so aa to eunijireKS tlie bleeding vetfseLs. Re- 
move piii8 in five days, and leave lijfiitiires to come away of 
llieniselvcs, with tlic li^iite*! tissue, strict antisc|t.sis to l>e ol>- 
uerved both durin;; the triinfhsiou and gul»RHjueat dressings. 

lyrLAMKP Breasts of Infants. — In young infante of 
either sex, one or Iw^lh of the breasts may Iw^conie red, tender, 
and swollen. On |»rei«urc u few drojis of milky fluid nniy be 
squeezed out. hut this pn-assure should never be aMourtf Df |)rne- 
tiaed. l^t the hreiL^t.s entirely alone. The trouhU* will diH- 
a{>i)ear of itself in four or five days. If atteiniitf* are foolishly 
made to press out the milk, pu8 may form, nud a lancet lie 
requiretl to oik'U the little ul>w.'et4*T always under antine[ttic pre- 
cautions. 



OpirriTAI-MiA NEONATORrM i(» an infectious purulent con* 
junctivitiis, due to the goniwHX'cus or sf»nie other pyogenic germ, 
iuhI ]*roduced by 4'ontncl with the eye of vaginal secretion 
from the mother during Inlwr, or by inltHled fingers, instru- 
menta, cloths, etc. Statistics show (hat hlinduetss in adults in 
about one-fourth of all cases is due to this disease. 

Symptomj*. — (h'eni tni^fHiutj and wuiietimes hieetiing of the 
eyelids; the ocular and puI|H'l>ral wnjunctivie are re*l from 
inteuAT ht/pcro'tttia, and the skin of the lids is often of a dusky 
timI or bluish color ; j/ntfut*/' puruUni dijtrhnnjr of a gray, green, 
or yellow tint The conjunctiva swells around the coniea, so 
that the latter appears sunk down in a circular depri'ssion. 
Bad cases go on to ulceration and sloughing of the cornea, 
with j)erforatitm into anterior chamber, if not properly and 
promptly treatetl. 

Trcatmrnt — Keep the eyes clean and free from aecumuIattHl 
pus by washing them every Inilf hour with a siituraled solution 
of boric acid, li<ls to be soparaled as widely as pnftsilde, ami 
the solution droppeil in pleutii^dly ; or the bulbous tip of a 



LABOR /y HEAD PnESKNTATWyS. 



251 



eye-dropper in plaa<I ultenmtoly in the inner nml outer 
It's of llu* liilt* nuii l\w sohition (tU)wly iiijefte<l witliiu thiMn. 
In place oi' the horir ar\d s<»rne prefer tt 1 : 50(H) liirlilori<]e of 
mercury soluiiun ustd iii the winir way- JWniL-,s tlli^^ autisi'i^ 
tic olenuHini^, uiiich must Ik' i'aitlit'ully ilmif, bolli ilay :iiul 
night (lient^ /mo nnrst'S arv re* pi i ml), drop inlo each eye, 
every iii;rlit Hnd every niurning, two dnn^ of a two |xt cent.- 
3<»hition (tf silver nitrate. After eaeli wuisliinj; place over the 
eye a lij;lit wet eoinprew. ke])l n)]d by conUu't with ice. Aa 
the i*yni|»loiiw l>ecome U-5*» acute, use the silver solution oiicf a 
day and reduce il8 atren».'th to 1 i»er cent., the Uirio aei<l (or 
bichloride 1 solution to be c(jntinued until euro is complete. In- 
form relatives to lH?\vttre of wmtJi^ion. Lwjlftte patient an<l 
burn all clotlm. coinprefwes*, etc., once u.sed. In labor <*asefl 
when infection \a rt'are<l, use one drop of a 2 [x-r cent, silver 
uitrute tfolutiun In each eye iia a proplkylaclic uicubure. 



X y 

CHAPTER XIV. 

lIKCnANIHM OV I.AHOR IN HEAD PRESENTATIONS, 

By the mechanism of hilwr we uudiTHlJind the o[>eration of 
the iiKH'hanifftI forrrn, and the execution of the merhaniciil 
nwvrmrntif, necej^sary to siHmre the [laflwiire of the child through 
and its exit from the [telvic (or rallier (wirturieut) canal. 

In studying it there are «i> prtsmtatiom tu he considered, 
vit : 

1. Ileml preacutiitions. 4. Knee presentatioi^ 

2. Faco " 5. Feet " 

3. Hreech " 6. Trauaverse " 



PoiarURE OR *' ATTITUDE " ' OF ClIfLD IN UtERITS, — The 
jiosturr of the f'hild in ntrto \a very much that of an adult 
when trying lo ktH.»|) warm in a cold IkhJ betore going to bleep, 

» The IfplMitPd! h*rm ** nttihiitf" l)irrafi>re mpana tlnj rrlntlnn which Itic (llf- 

ft.*n.'.r , ' ' ■ ■ t.l'f'Ui^ly y^cmr to mf^lt other— h nu-ititInBr)uUcdin'iTrmfnim 
thi- ' nii<1 ■' it'tfitUm," riB wtll Xnf **'ki\ litiiiitt<liAtu1y. VtduAp- 

l>cu<u 111 olwU'irUiU Som«tiiiiitur«. 



252 LABOR IN HEAD PRESENT A TrONS. 

Fio. 96. FlO. 97. 









ExCTtmO!**!.. 

97, m, 99, ion. ATitl 101 rcpreicul Lhc lU pfwitlons nf tho occiput 



HEAD PHESKSTATIOSS: FOUR POSITIONS. 253 



vit: the 8|iine i-urveti forwunl, the fiice lioweil toward the 
chest, the thighs Mexe<i \i\you the alKiouieD, the lepi toward 
the thi^hn. iiiui the tiniiH tlexi^l hikI fuhleU. u<:nins iht: breu^t. 
The chilli, in utiru, thus Ht-xed iind folded, it) more wunimot 
and oc('U|iit« ti':v sjuuv iliun It rx»uld ilo in tiny utiirr jN>hiur«; 
\U whole frame H|n»r<nuhttf tlie ow/r//yrm of the uteriue cavity 
in whii'h it ri>|«)S4'j*. 

Now, when t-ither r/n/ iif this WvioX ovoid prewenta, other 
things l>eiii^ norninl. delivery is ntet'hanieally jKisnihle. When 
it prea«nit8 r/(MWMw, ilelivery is inijHjusihle. llenre, prewenln- 
tious ut* the head, fuee. breecli, kneeti, and feet nmy he eousid- 
ered natural pri^ttentatiuutt ; white trau8ver»e pre}M:;iitatioim aru 
prviernatuitii S>n»etiines head and face presentations are 
calU'd 'HTphuiie" premutations, hei'uuse the cephaiie (or 
hniin) titd uf the ovoid pres4Mits : wliile lireeeh, knee, and 
f<H)tling pri'rtfnlntionH are ternied "|»elvir'* ]>resentation.s. 
I)eiitutie the [lelvit* or eaudal eiid of the ovoid conn's rtrhl. 
The long spina! coliunn m%i«t. oorue oue end tiret — either head 
or tail. 

Head Prkskntations. — Ca^es in which the head presents 
at the u8 uteri ur i>elvie hritn. 

Tin: Foi.'R '* PoHrrioNH '* ok Hkad Pi?i->entation8. — By 
the term *'/XMri/i*on*' iw applied in the rneidmnisni of lahor, wb 
mean the puMtionnl rvhUhm exUihuj itt'ttvefn a girm point on 
the jfretsmfiug partj ami rrifain oilier f/nv« points n^mn Ihf 
fietvtA. In hea<l pre**culation the oceiput \& the ^iven point on 
the preRMiting jiart, and the ^'iveu [>oinl^ on the |>elvis are the 
two acetabular and th*' two wirro-iVmr ftt/nrhondroees. Thus the 
four jx)»itioui* of u liead pr(.>>eiitation arc : 

1. Oceiput to Ay/ acetahuluni ( left oivipito-auterior)' (ocd- 
pito-hrva-anterior ). 

2. Oi'ciput to right acetabulum (right occipito-auterior) 
(occ.ipilo-<lextra-anterior ). 

3. Oiripiil to itj't t«u'n>-iliac! syuchuudruftis (left otripilo- 
|)oeterior) (tM'cipit»>-liiVH-|Mislerior). 

4. Oeci}>ut to right wuTOJIiue tfynchondrosis fright owipSto- 
}Mj0terior) (tK'cipito-dextra-jioBterior). 



\ 



I So cnI1<*«1 becAUM' tli«> <K-rli»ut U pdlnllnit tA> ihu trft Hn<] /uniard. 
pUu of iiumciicUturc u iijipuvl tu lliv utlivr |Mi*lt{ittii. 



Thcumc 




ExncpTionAi^ 
Tfga. M. Vr. «, M, ton. ud m rvprct^.rii Uje »\x ftrmiUoM of Ike occiput. 



LEFT OCCIPrrO-AyVEBIOR POSITION, 



269 



puHitions we 



tlio dirertian of exU'nsiim in this I* O. A. ptwition is surh as 
lit niuke tlie iX'tMitilJil \tiAv j;o upwanf ami Jurwirtl tifward the 
mans veneris. In the K. O. P. uncJ L. O. P. 
ahull Hee ihiri sttniptirnes rcversoii. 

It \a worthy of roniurk ajnl illutdrnUrs uaturc'V a*1a|)ialiou 
of uifUnM to ends — in thin catici the adairtntiou of imHscmjcer to 
piisNijifi' — that wIk'u anterior roiati(»n of the o<xi|iut b foni- 
plote and the hetul i^ altoul to eM*ape hy cail^n^iou, the prn- 
jrrlirifj rmr^jx cumft* esftrthj in cmitari with tlie iintrnor fmttMnte/U^ 
wluww yieliliiiK fluri'aiv orten* lew n*if*l«un'e than a hard \x>ny 
one wuuld do. (Hw Fig. HK^, |mge 25H.) 

Fw. 101. 










- i : the 
nden 




254 LABOR IN HEAD PIIESENTATIONS. 

Very rarely the occiput points directly in front, to the sym- 
physi:i puUis. or (Iir(!cily U-hinil, to the ssacnil [irurnontory* thus 
Dnikiug tiw more ]>ositiouis ()*/xin ull). But these two luay be 
left out Thvy unually Itec^me. converted into one ot* the other 
four at the be;)rinnin);; of hibor. 

The order of <;reiitcst fritjueiicif of the four [lOBitions is as 
fol lows : 

Fim-. 0<*cipiit to ff;fi acetflhulum, L. 0. A.* 

Sticoiid, OiritnU to riijht Hiirm-iliuc syncIiundroHis, H. O, P. 

Thinl. Occiput to ritjiit arclnlniluiii, H. O. A. 

Fiiiirtli. (_)criput to Ifjt rtucroiliiic sychoudrotsiH, L. O. P. 

Thiri onler of fretpjency is worth reniemberiufr, but to cail 
the |Kwition3 Hrst, j«*'foiiil, third, and fourth is worse than use- 
leta. uml hml lu'ttcr he oiiiitle^l.' 

If the Htudent U' not already familiar with the terms and 
measurcnu^nls trjvcn in (hi^'rihii;;.'' tlie [telvis (Chapter I.) and 
Icetal head ( L'haptcr II. ), ht* .^liouhl review tneni tn^fore 
nttcmplin;.' to Iciirn the inw^hanisin of Inhtfr. In the follow- 
ing de>»rripliuii it ti* detiij^^uetl to ^ive only the main principles 
of the mcrhunij'iii. leaving exceptional o<Turreuces and slifjht 
deviulioiiH and obliquities of no ^reat practind value, entirely 
out. A simple outline sketch had iKiUcr be learned first. The 
fiiu^r fihiwlefi of variation («n be pul in ancrward. Mixture is 
confusion. 

Staoes of Mechanism in Head Presentations. — Th««e 
are: 1. Flexion; 2. Descent; 'S. Hotation ; 4. Extension; 5. 
ReHtitution or external rotation. 

Mechanism IN Left Otx'ipiTO-ANTERioR Pof*iTioN COo- 
ciiHT TO Lei-t AcETAni'LUM). I, Flfi^ioii, — It unist l>e 
rernend-jcred thfit the ftctal hc^ul is (roujrhly ) ep^-Rhu|>f»h and 
nieiwnre^, from the hit/ end of it to the liftle end (from the 
o<N-ipnt to the chin i. !S\ iiu'her*. While the oc*ni)ital |>o!e of 
the head is at the left lu'etabuluni. the chin-[>ole nuif^t be wwne- 
where toward the rijrht mu'ro-iliiw synchondrosiis. and a line 
drawn l>el ween thcst^ two jHdvi<* iM)ints is tmc of the oblique 

' I,. O. K , /.t'ft ni'v\it\Ui'AuUTitn; I. (i. V., Lvti Ovvi\M(*-l\}sWrU*r 
' Nni'ffrli' stiit«'(l ilitit in i-v«'ry lito vcrti'X r""i'M'nlanini<. 711 itre I>. U. A. \Ht<i\- 
tltm<(. iiu>l :«i K. o. v.. nil fiXhi'Tt- twine «*xlrfmcly mrc excoptlons. I'nif. rum- 
eniiiJi lltrnrcBnpu: h. O. A..67; K. O. F..a): R. 0. A., 10; iiad L. 0. V., 8 per 
Ceut. 



LEFT OiVJPITO'ASTi'JtlOn PnSITIOS. 



255 



(iiametcn* of the Itrini. hihI ineiwurL's -1^ wifliea. Ih ft bead 
fiirtim-tor of oA inohcs. tlH^n, tryiiijf t'> jmsn a iielvic (lianieter 
of 44 ? No; the lunvLMl uttitiniL' of tlu' rhilil's hea<i in ttterot 
alremly meiUioiiie'l, ket'i»s its ehiti-|M)lf tiltt*! up towar4i tho 
uterine cavity ; an*! the in*ri[iitul jmle tiltt-U ihum tovviinl tfi« 
oe uteri aud (►elvis, so that the t'oreiieud instead of the thiu is 
really at the rij^lit j^icro-iliao jiy»ehondr(w*i.H. ami it is, liiere- 
fore. the oenjiilo-frontal diameter of the head (4i inches in 
length) that is apparently trying to go throngh ihe ohlinno 
pelvic diameter of -iA. JJut this wiujld he ti>o tight a lit. T i)0 
eliin Miiist l)e tilte*! yet more <leeidedly toward the steriiuin of 
the child, and the (wciput V>e matie to dip more deeidcdly 
toward the entranee of tlie [K*lvis. in onier (hat the uval- 
ahapetl head may enter the brim more or less eeuUvise, Tliis 
ia Flexion, so eulled hw/uiiw? the child 'e ueuk ia fiext'tly and the 
chiu pressed agaiuyt the steriunu. Fig. 102 sliowa diagram- 
matieally. the etfeot of flexion in pormitting dcsicenL In tho 
upiwr hea*h uutie.xed, it is seen the 5i-iuch oceipito-nieutal 
diameter cautiot enter tlie 4i-iueh diameter of the Uritn {repre- 
sented hy the ring at the lower jMirL of (he lignre). The 
middle head i^ HiXtMl stiffirienlly to <i(.^tcivl. The lower head 
shows an impo«sihh' degr<<' of tlexioii— inijK^ssihle wlien (he 
head is attached to the neck — and nnih*r'irahlc, iw it woidd 
pertnit the head aliaosL to ilrop through the |x*!vis. The line:* 
and iiurnerala repretsenl inohes. 

What rnuitfj* HexioD? The fon*e of uterine contraction is 
transmitted through the IhhIv of the fhild to it.s heoAtl hy moanH 
of tlie spiiial eolinnn. but the cervical end of tlie spine> where 
it joins the cranium, is not in the centre of the biu^ of the 
»k\dl. midway U^tween the two |»()le«. but is nearer Ihf occij/iial 
pofe : this hist, therefore, bears the brunt of nterine force and 
ifl ma^le to dip down lower than the other fK)le. Moreover, 
the two poles meeting e<jual repistance from the ciR-le of the 
OH uteri and [Kilvit brim, the resisting force exerted uinm the 
chin or frontal ]Kde will be more effective iKHtiuse it is* acting 
on the eml of a longer lever than thai ap[)lied to the occiput, 
henr-e the dnn and forehen<l are tilled upward. 

It miwt l>e admiu*il, however, that Hexioii of the heail ih its 
normal attitude iluring pregnancy Iwfore hilHir begins iiud 
when then fore the muMrit of flexion nnwt be diHerenl from 
thueejufli demrrilRHl ; but that the Hexiou, when inaufliciciit, is 



LEFT OtVWiTO-ASTERIOn POSITION, 



257 



more or leas parallel with oh<- oblique cliaiiieter of the pelvic 
brim, the transverse or bijmrietal diamoter f3i inches ) occu- 
pies the tifhrr oblique (4i ). Hence there in plenty of room for 
thai to |)a*!i. The bi|»arict«l fliameter is alsft nhuut on a level 
with the plant: of the sn|H'rinr htrait, owitij;; to the fuiuln.H iit4Ti 
being ho tiltetl t<>r\vnrtl lut to l)rin^ the uterine axL« iu a liu« 
with the axii \ji the plane of the brim. 

2. DcM'.ent. — The hejid having Ikh'u ti!te*l eml\i'iHe by flex- 
ion, it enters, occiput first, the |>elvie brim, ami flctfrrmii* into 
the pelvic cavity. It ^oe« on down (the mviput ritill towanl 
the left acetabulum and forehead toward the right tmcro-iliac 
syuehondruwiji) until reaching the [Kilvie lloor (the bottom of 
the btLsinj. 

(Notf. — While flexion and descent are thus deecribe«l as 
Beparnte. proceas(% and while the fomier is necesHary to iLe 
latter, it muHt not \te flupjiosed thai Uexion U n.miplcte l>efore 
de3»cent begins; on the contrary, they go on simull^ineously, 
each increment of ilexion Unng accom|mnie<l with an incre- 
ment of deacent) In fiAi*t the whole procesn of ]a1>or. from 
beginning to end, is a ticsceiil or proj^n-tKiou of the bead ami 
b<Kly of the chihi, from the inlet of the |>elvi9 alw^ve, to it8 
exit at the outlet below. r>eAcent can only be profitably 
conBidereil uh a separate proct^HS iu that it irt one that must 
take place, before the next step, vis.: rotation, can become 
posaible. 

3. Uofaiion. — The lu'n*l having de«!ended to the |x*lvic floor, 
its occipito-frontal diameter (4^) nou> tKX'upies the oblitpie 
diameter of the inferior 8trait> which, however, raeaHure^ onljf 
four inehfn. It cannot go on. Siunelhing must wcur to bring 
the long diameter of I lit* head parallel with the an(firtj-jttmttfior 
diameter of the outlet, which we know mca.sureH 4i inclics, or 
oven i> when the coccyx w punhed back. This ia accompliftbcd 
by rotation. Near the end of its " descent " the occiput Hlrik** 
U»e p«*lvic floor and the i^lanting surface of Injnc in front of 
the if*chial i?pine — the so-ctilled left anterior inrVwM pfttnr — 
anil glitliiig ilownwiird, forward, and inward toward the median 
line, it rejurhi^ the Hvmphy.si.'* pultis, while the foreheatl, rotat- 
ing downward, /«jr/-rmn/. and inward toward the median line 
(along the righl /^w^f nV*r in<'li»e* I pbini*). rcacbet* the centre of 
the wuTiim. Thus the ovoid head ban t-ome ti* (K-cupy a [Km- 
Lion agreeing witli the longe.'ti ( auLcn>-()ostcrior) diameter of 

17 



258 



LABOR IN HEAD PRESEi\TATJOyS. 



the outlet iiml the ixx^ipital |)ole is almost ready t^ e8<>a|)e, end- 
wittt% thn»ugh thf iiiffriur Htruil. (Fig. 108.) 

The iiiHueiiof of tlie " inclined planes" in causing rotation 
has lattorly Im^h lioubtcd ; ami other theoretityil explanations 
have \)een jriven. Hut the?Ki theones are of uo very j;reat 
inomeuL The prn^tical fact renmins, that in the normal 
inechaniHQi ot* lal>or the head does and must rotate iu the 
manner descrilied. 

4. J'Jxien^ioiu — The hea<l now stretches the |>eriueum and 
«>ft parts into a kintl of jrulter, which ^constitutes the fleshy 
continuation of the juirlurient raual. The oL*ci]>ut deaccnds 
l>elow the syniphy^iH j)ubis and pa:}t^e8 ou t>etween the puhic 
rami, until the hijiarietal e<]uator of the head ^tn into the 
pubic arch. The hack of the child's neck Uieanwhile litH 



Fl.i. nw. 




Occiput >t Inferior alnilt after roUtlon. 

Br|uare1y against the posterior surface of the pubic symphysis, 
and rftitinj: there immovably, the force of uterine contrataion 
is exj)ended U|X)n the ehin-|K>le of the head ; hence, as soon as 
tlie resistam-e of the t«ifl parts permits the ocrijiut Ui he^u\ to 
eBcu]>e. the chin is releai?ed from its w>ndition of flexion, and 
extension is said to have lieirua. Finally the forehead slips 
by the projecting cwcyx, the parietal etjuator of the head 
emerges from the vaginal orifice, and the inniiediaio retraction 
of the elastic fjerineiini over, successively, forehead, nose, 
mouth, and chin, caui^es the occiput to rise up outside and in 
front of the pul>es toward the mons veneris. Thus delivery 
takes plac-e l>y the head describing a circular movement round 
the fixed centre of the pubic arch — a movement exactly the 
reverse uf flexion, viz., extenehn, (8ee Fig. 104.) Rememl>er 



LEFT OCCirrrO' ANTERIOR POSITION. 



259 



the diref^twn of extenniun in this L. O. A. pomtion is sui*h as 
to ninke the t>t'(!i|»ilul jKtle go u^hntful inu\ furwurd t^iwunl the 
nums vemriH. Tn thi; H. <). V. iinij L. O. 1*. iHJttiliiinjs we 
shull see lln.n [*iniifliiiies revei"sed. 

It iti worthy **!' rt^nwirk ami illitstratea nature'^ adaplation 
of intiiiK- to L'luls — ill thin rase tlie atiaptntiou of (niriSKiiger to 
|M»*eage — that wlien aiUrrit>r rolntiou of the CKX'iput is ix>in- 
(>IeU* antl the head iH alK>iit to <'S<Ht|>o by extetieion, the pro- 
jectimj rorci/j* comfn rrtwihj in rouUtrt nuth the antrrwr fontaufHc, 
whose yielding Hurfaee uflors lewii rej*is!anee than a hard Wmy 
one would do. (tree Fig. 108, jiage ii5^.) 



Fig. lOt 




Tpwird cxtonslnn of ocdpnC 

6. RfdtitutiotK rExtenml Hotation). — The head, after beinp 
coni|ilelely Ijorii hy extension, hunt's out of the vagina; the 
ehiti dn>ji|)itiK luwani the ami?, the vajriual orifice enrirclefl 
the neck. The head next twiKt-s or rotates, in such a manner 
an to hriujj: the oeeiput toward the mother's left (hi^h — the 
thitrh n>rn'S|Htn(lin^ to the a(vinhnIuiM at whieh it t»riginally 
pn-H-nted. The puqwc^- of thin nmuuMivre ii* to facilitate 
delivery of the shoulders. Their hm^jesi diameter ift, of oounw, 
the liii^enimial — fnan one acromion prwe**!* to the other. Thin 
diameter entered the brim and ilcscrnded into the cavity (»f 
the jK'lvis, parallel witli the ohli^pie pelvic diameter extending: 
fn»m the ri^iht aceljibiilutu to the U-\\ saero-iliac .synchondroHia. 
Bui havini^ reachcil the iiijtrior tilniiU the bisaeromial iliam- 



2fi<t 




LAHOB IX HEAD PRESENTATIONS, 



eter muHt rotate from its olilique direction in tlie pelvis to the 
antcro-ixwterior one. Hence the right shouMer — the oue 
nearer the puhefi — rotnti^ to the put)ei*; the letl nhoulder — 
the oue uearer the sacrum — rotates to the flacrum. Thii* rota- 
tion of the fthouMers mside the pelvis eau-sos rotation of the 
head outjiide of it. The shouUIer at the pul>es itsnally fixes 
itself there, while the otiier one, at the f)erineuni» swin^ri) round, 
desi^ribiiig a eireiiiar niovemeut {ns the occiput did;, and comes 
out first* (See Fig. 105.) 

When (lie fhoiilderB are de!ivere<l the rest of the l>udy 
usually 8li|>$ out at once, without any s^tecial inechaDiz»m. 



no. 105. 




KestltuttoD. 

Mechanism of R O. A. Position (Oocipct to Right 

ACKTAIMTLITM). 

1. Fferion, by which the chin tilt* up and the oc(!iput 
down, a> as to get the lou^ diameter of the head more or lees 
endwise to the pelvio brim. 

2. DeacenU by whJcJi the head descends, occiput first, thn>Ufrh 
the brim, into the cavity, down to the inclined planes of the 
pelvic floi»r. 

M. JifitiiHoti, by which occiput (jlides alon^r right anterior 
inclines] plane. <lmvnwanl. forward, and inward to «yniphyi«js 
pubi.s : and forehead glides along hft [»o.sterior incliued plane 
to middle of sacrum. 



MBVHAJilSM OF R. O. A. POSITION. 261 

4 EjUetisiotij hy wblrfa (Mwiput escape un<Ier pubic arch 
aii<l risfs up outj-iiK', Itiwanl iiioni* veiierin. wliile foreliend, 
noH€, iuuuLh« £111(1 rhiii i^iK'cehflively e±4caj)e at [>eriu(Hiiii. 

Fiu. 106. 




Dtaffnun matte view of meohnuliini In « IcA-r)Cci[ittu-Rntcrlor poHUan of a head 

prrjimtiiHim. 

6. Rft*t!(utwn (exti-mnl rotaliorO. I»y whirh *^?<*ipnl turns 
lownrti inotlnTV r'ajftf ihijjh Dho ihi^h corri'HiMMiiliiijr to ace- 
Uiliuliini at whirli i( orj:iiially prr!*eiit<*(l), in wmwrpK'Hw of 
shoulders rotjititig iip4)n inolinod planes — leil ithoulUer to 



262 



LABOR rS HEAD rRESF.yTATIOy& 



pubep, right to cotxryi ; the latter one gejierally eKra|}eii &rsL 
Delivery of the b<Kiy. 

Thus we have tie»cribed the two anterior pubiiions of the 
occiput : Lb O. A. and R O. A. Next come the two posterior 

OUO). 



Mkchamhm of R. O. p. Position (Oocu'Lt to Rioht 
6A(K*>-Ii.iAr Synchondrosis). 

1. Fitxiofi^ fuiii 2, De^cjiU as \\\ auterior positions of the 
occiput. 

^. Rotation. — Id the larpe majority <tf oai^es (IK;) |ier cent) 
the occiput rotutee all the way rouud to the symphysis puhis. 



Flo. 107. 




Extension aft«r potitnor roUtloo. 

In tiding so it paR^os tho ri^lit acetahulum, hut it no sooner 
reaclK* thin jx»iiit than it Ifewiniw* pnuiically and in reality 
a rijjht (inUriur ]x)sition, ami the rest of the nii'ohanism w 
prcciiti'ly the same aa alremly «leMTil>eU for the R. O. A. poei- 
tioD< 

In the small minority of cases (4 per cent.) the occiput, 
inntead of rotating forwnrd, rotntrs backward to the pacruni, and 
tlic forehead comes to the puhes. 

Then f^:)llow8, 4. ExU-^mtm, which takes place, not upward 
toward the mons veiu'ris, but the (M-ciput rpcapt-s over the 
|M'rineum, and is depresaeil outside of it downward and back- 
ward toward the arms, while forehen<l, nopi*. mouth, and rhin, 
Hucceiuively emerge under the pubic arch. (.See Kig, 107.) 



EXPLANATIONS OF POSTERIOR ROTATION. 263 

5. ReslitiUioTU — By interaal rotatiou of the shoulders, as 
alrenily expliiincHl. one goes to jmlx\s, the otiier to sacrum, 
and thi: ocei]uii rolls arouml to the rij^^bt tlii^^b (the ihi^'h cor- 
res|)oinliug to the sacro-iliac synchomlroeia at vvbieb it orig- 
inally preseiiU'tl). 

Mechanism of L. O. P. Position (Occiput to Levt 
Sacro-iliac SYNciioNURoaia): 

1. FifiJ-inn. 2. Descent, 3. Rotatwn-, in the majority of 
cases all the way round to the symphysis [Hihis (when, on 
reaoliing left acetfthulom, it, of course, becomes converted 
into a L. O. A. [Kwitiou ) ; in the miuority of leases, back- 
ward rotation of occi|mt to KatTUui. 

4. Krfrnjtion c>f occijiut downward and backward over peri- 
neum, while forehead, luwc, and cbin, Hucoejssivcly ew.iHH* under 
pubic arch. 5. RfMiUtiwn, internally of shoulders, ri^dit one 
to pubert, left Ui ciMx^yx : externally of (H'cipnt to let! tbi^b 
(thigh correH|K>n(ling to tbe sacro-iliac synchoadroinK at which 
it originally presente^l). 

Explanation op Posterior Rotation. — In those few 
ca8(» of (wcipito-posterior positions where the occiput rotates 
to the sacrum, tlie circumstance is due to iinpirfeat jtrxlou of 
the head, ho tlisit tbe fon'hcjid is to*) low. In reality it is, 
therefore, anterior n)tjition of the rorebciid which cnnw* |)os- 
terior rotation ot* tbe f>ccipnt, in obe<lience ti> a fjencnil rule, 
that whichever |x>le of the heatl '\» the lowest in thi* (lelvis 
will rotate to the pubic symjdiyHii*. <)ccai*ioualIy, however, 
the forehead, being lowest, \v\\\ stick near the a<^tabnliini, and 
then rise a^ain, f>erniitlin^ the iHriptit to dest'end nloii^ tbe 
opjMwite siicro-iliac «yncbondro8ift, when untcrior rntnfiou of 
the occiput, all the way round to tbe pnln-s, will lake pUxce 
jufit an lh« hcail U altout to escajw from tb«* vidva. 

Still another variation may tnvur when the (»ceiput hoH 
rotattvl posierioriy. viz., instead of the i>c('ipital |Mde es<'aping 
over the margin of the |>e.rineum, the forebearl, noso, and chin, 
successively, e«oajw /ijV under tbe puhie arch, when tbe chin 
risetfl up toward the mouB veneris, ami the <Kreipnt comes out 
itui at the perineum. In fact the case w cfinverted into a face 
presentfltitm just befitrc the head in lM>rn. This mtKliHcatinn 
of the usual meehauifltn is exceptional. 



284 LABOR iN HEAD PRESESTATIOHS. 

Fia. loa. 




Dbi^nuniDattc vicwofmccbnnlKni in R. O. p position, niter poefrrlnrrotaltoB 
uf occiput. 

D1AGXO8IS OP THE " POPITIOX " IV UkAD PrKSKKTA- 
TIONR — In the \*. (). A. Btifi L. (). p. [Hisilionj', \\\v purl of 
thi.^ lii'ivl fii>l touchfd hy th(^ cxnmininjr fiuL^er ij* thr; rigrht 
piirit'lal Ixtiie ; in the U. O. A. niid IL <). V. \M\g\x\nwp. it ih 
the leU (HiriHal Ikhic. In t'thcr c:»st' it is (hat [«irirl«! iione 
wliirii lies nenn^t lh<* piilu'i*. Tliin ih t-iisily niiiK'rsUrtxi hy 
romomliorin;; thiit x\\c head eiilcr8 the i^elvin in 11 line with the 
h»ni! uxi^ of thf utfiim, which \\\it%'X» with tlie Hxiti of the 
phinc of th<* su(M'rior Htrait, whih* the Hn^er entorK the ]>elviH 
from l>elo\v, and more in a line with the axis of the inferior 



PROQXOSIS AND TREATMENT. 



265 



etrait, »« that il ntM'Pssarily toiiclieH the sldr of the preftenling 
head. One parietal Ixme Ifxtks iipwanl aud backwanl, Uiward 
the sacral proinonlory, llie other downward and Ibrward 
towanl ihe pulu*.'*. The luUer one is tt)uebe»i iirat. Then hy 
pushinjr tiic Hnjjer a little higher up aud further haekward 
toward the Mieruni. the sa^Mllal suture, runniufr between the 
jmiietal hones, umy Ite felt extending ubru|uely aert)*w the 
jx-lviH between the n^'eiabnlnin and oppdctiie Huero-iliae nyn- 
ehondrutiia. It* it Ik? a L. O. A. iH.»»itiMn, the linger, by iol- 
lowin": the sagittal »uinre toward the lell aeetalmUnu, will 
there f]ud the i^mall trianj^ular luiitunelle at the Junetiuu of 
the sa^^ittal and Ininbdoiilut Mituren. If it l>e a IL O. A. |K)ei- 
lion, tliifi fnntJinelle will l»e ilb«ytvered hy Ibllowinp the wane 
suture toward the right aeetal)uhnn. If il be a U. O. 1*. jiosi- 
tion, following the wigittul HWture toward the Ujf neetabulnni 
will uol bring the iiuger to the HUh: foutiinelle, but to the large 
niendjranous anterior one. So in a L. O. 1*. jKwitinn, the 
finger will find the large fontanclle jii the ritjjd aeetiibuluni, 
by following the ^gittnl suture in that direction. In the two 
]X)t)teriur |Mtt>itioitt4 (la^^t mentioned ) the small triangular foD- 
tauelle cannot Ik* touched at all — it is entirely out of reach. 

In nhort-, having felt the fuigittal HUture, follow il towtird 
the acetabulum to which it points (it vmM point to one or the 
other }, and there will be found the posterior fontanelle in ante- 
riar |Hi8itioni* of the (x-ciput (right or left, ns the case may be) ; 
or the anterior fontanelle in poettrior pot<ilioui» of the o^xnput 
(either right or left)- 

I«at4!r in the labor, when r(»tation ban taken plaiv, the fKH*- 
terinr triangular fontanelle, in anterinr po/itions, will be felt 
toward the Hvmphy^b^ pubib, the Migittnl suture running back- 
ward toward the sacrum ; while in tliow.* |K>*(terior (lotiitions 
where anterior rotation of the (x'cipnt does not lake place, the 
large. mernbrunouK unmistakable anterior fontanelle will be 
felt toward the pubic syniphysis. 

The mo4le of making out tlie poxitiou in head preKcntatioiis 
by pnijMttiou, viz., by recogniaiing the relative [Hwitinn of the 
child'8 Intrk, forehnuif and oc^ciput, haa been alrea<ly explained. 
(Bee Chapter XII.) 

Progkopip axp Treatment of OrrrpiTo-ANTKRioR Posr- 
TIONs. — Prognosis favonible in *> far as the mccbaniem ifl 



266 



LABOR ly UEAIJ PRESENTATIONS. 



concerned, aud no a»iiHtant.*e roi^uired in ordinary cases other 
than general attentions iilready nieulionetl under "TIu^ Man- 
agemcut (»f* l^lwr." 



PROGl 



Or 



P<wi- 



NOSIS AXn 1 RKATMKNT (»F ( HVIPITO- POSTERIOR 

TIONS. — In the inaj'jrity of eases the siinie f\» iu anterior j*iwi- 
tioiui. In the minority of eiwes, where anterior rotiititiii nC 
the oci'iput fails to lake |ihu*e, a long and dittieuU labor nniy 
be anl.iei[)ated, owing to the diflieulty the o*^N:uput eueouuterB 
in escaping over the |K'nneinn. on aeeouiit ol" the |M)Klerior 
(«arral 1 wall of the pelvl.s Ikmiilt «» much deeper than the ante- 
rior (pnhic) one. tor^'ejjs may Ik* rw[U]rf!d to p4»nipk'le deliv- 
ery, tiie sliort Htraight ouets I>eing pret'erre<l. The |H'niuMjni is 
enormcmsly (lirftendeil and requires additional «ire lo prevent 
nipture. 

Various ex|>edienU have lieen devis^ed to pnanote anterior 
rotation of the (Ki'ipnt wlien it dtn's not (K'cur s|M>ntaneotwly. 
Thus, since we know |Kwterior rotnLiou is generally the result 
of hnjurffct Jlf-rion (the forel^ead l»eing lo<j low, the oeeip)it too 
high), we nniy strive to remedy the flifticulty hy makiwj flex- 
ion jierfect. This caii he done hy preKsing two fingen* of one 
hand upon the forehead thiring the pains s<i as to push it up, 
or at least keep il tVoin »^>miMg lower, while the force of 
uterine ctaitrjiction in tlieu ex|»ende*l in ilepressing the tM-rijuif. 
A vet'tis may at the name time he app[ie<l over the ocn])Ut to 
assist in i>ulling it down. The ohject is to get the <^»ecip(jt so 
low that it will pass bfhw the spine of the iHehinm to the ante- 
rior incline*! plane and rotate fonmrd, while the forehead is 
kept high enmigh to jias^i tif}tn'f' the op|M»Bite ischial spine and 
rotjite ha<'kwanl. Rotation forward nujy wtmetimes Iw accora- 
pli>*hc*l with fon'qif? while making traction. 

If the pelvis Ik' large and the operiit"r*H hand small, the 
latter may l»e passed in alongside of the hea<l. an<l the (xriput 
drawn <ilili«piely downward and forward to the puhes. Another 
plan : Etheri/-e to full ana^thcsia. I'ass a hand into vagina; 
gms]> hcjnl, and steadily and gently push it up out of the 
[)elvis, nfioiv Hnjn-rior strait. Then flex it, and rotate occiput 
forward. Hold it so until the pains, aidefl hy pressure of 
other hand on alxlomen. push it down again into |>e]vis. in its 
now occi]»ito-anterinr |»o»ilioiu Forcejw may be retjuired to 
complete the delivery. 



PACE PRESENTATIONS. 



267 



Posterior roUilion of the tw^'iput ia (^[teniully likely to occur 
wheu the head ii^ unusually hnft\ 

When, ill octipilo-jKiflterior jnwitioiis, the oociput Atu already 
perlornierl posterior rotation — tluit it*, when it hatt gone from 
thi' sucr*>-iliiic synchoIulro^■is to the hollow of tht* hncruni, no 
further aUeniptc* t^hoiitil he made to Itrin^; it forward ; it must 
lie ili'livered with the iKX'iput iwhintl, the straight foreepfl 
hein;^^ usfil. in onltr to nlh>w backward exteusion of the occiput 
down over the jn'riiieiini. 

Profe*wor IVnnwe, however, advisei* that even after [xisterior 
rotation of lht> ueeiput haii takeu ]»Uii'e a firm hut prudent 
attempt should .-^till lie made with a short r^trnijLfht force^jeii to 
ftirt'f. r4>tation of the tK'eij)ut to tlie pnhis ; and in nu^o of fail- 
ure thus ti> ar'<*<nopiish anterior rotation, or to deliver by trac- 
tion whiUf ill*' iMvijuit renuun |>osterior. he urgently rwom- 
rnends an imniediute resort to endiryotoiny, in the iutereiiit of 
the niolia'r, evtni though tlie cliild he alive. (Hirst's! Ameri- 
cati StjMrm of Obntrtrir^^ vol. i. pp. 5^?^, fii^\),) While it is 
true (he pmlongeil lalwr and cranial eompression jeopardize 
the ehihl's life, the method of Dr. Penrose is» nevertbeleaa, not 
geuerally concurreil in. 

Rwently Kytnphysi(»tomy has l>een .<*ucee«sfttlly resorte*! to 
in eaw^i wlicre the eliild luw not already In-en sL-riounly injured 
l»y attempti* to deliver in other way.*i. 

Finally, it is especially in (X'ei|>ito-|»oflterior casefl that time 
and f)ittintrt' iire ri-ipiired to allow monitlintj of thi' hea<l, and 
tli/fitntion of the *M»ft )kart}< ; but a<*i**lan<'e must he promptly 
rendertnl at the very liegiuiiing of t^yniptomi* iiitlieating ajj- 
proaehing exhaustion of either the woman or womb. 



CHAPTER XV. 

PACE PRBBENTATIONH. 



Is fw^^ pres-'ntntiona the child's head, instead of being 
flexcil, is extended, wi that the Wn'/i end of the oeeipito-niental 
diameter Ih tilted down Utwurd the entrance of the pelvii), while 



268 



FACE PRESENTATIONS. 



the occipital end is pressed up toward the chihlV Ixick, just as 
tlie cl»in woti pros^nl lowurd the child's Hteruum in head pre- 
sentations. 

CtiHHfH. — Any projei'tion Iwtween chin and tftcrtiuni inter- 
lerinjr nu'chuniriilly with Hexion of the chin, such as rnngen- 
it4il jriiitrt* or othrr tinnors : hydrolhnrax ; wvcra! mils of 
funis round the necli, etc. ; any projwtion nit'cluiuicnlly arrest- 
ing dt^ceiit of the (M'<Mput, and ihu« o^nin tilw^tnictin^ flexion, 
Buch aa ovuriun, tihroitl, or other UimorH of th<* mother's part9 ; 
narrow pelvis ; a verj' large or iomj fcetal he^id ; csccemre lat- 
eral ohlii^uity vf the uieruA. This Inst is the in*>8l common 
cause. It |»roduce8 extension, and conwipiently face presen- 
tation, in the foIJowiii;j niauner : Most «»**es of face pre«'nta- 
tion were nt Hrj»t head prcficntuliouB. Now, if the occiput 
were toward the letl aoetfihulunj in an onlinary head presen- 
tation, and the fuuiluy uleri were tilte<l much toward the right 
sitle, the <lirec'tion <tf force of uterine contraction would he *«uch 
ac> to prc?*» the oc^-ipital ]x>k' of the occipito-meiital diameter 
U|»on the left edge of the |ieivic lirim, wjicre it wouhi reiuuiu 
eolidly tixt*<J, and the ut^TiiU' force wouhl then operate upon the 
other (chin) en<l, and force it ^lown iiit*) tlie pelvic cavity, and a 
feoe presentation wouhl re^^ult. Thus it is that poHlerior y/c^W- 
iioHA of fa<'e i)regentution are nutre frwpicnt than anterior 
one« ; they were change<i htad presH^ntatiousi, and the pujtiiion 
in liead cjisi-s is usimlly fM^cipiti>nnterior ; tvhnt changt^, as 
juHt de»HTihe<l, (he chin ii» directed hehind. 

Very rarely the fare presenlH originally, and i.«i ;io/ a devi- 
ated head «a»e ; thet*e are supiHis***! to o<'cur from the child 
having had convulsions hi iitf-rn (opisthotonos). 



PoemoNS OF Face Pri^extation. — The given point on 
the presenting part from which the |M»sitions of a face presen- 
tation lire named, i^ the chin (Ijitin, "ni/*ii/n7/i "). 

The nnmhrr of |xi8itionii, like thoee of the occiput, is four, 
SH follows : 

1. <'hin to letV a^^-etabulnm (left mento-anterior), L. M. A. 
(mento-laiva-anterior ). 

2. Chin to right acetiiHnlum (right mento-auterior), R. M. 
A. (menliwlextra-anterior ). 

3. Chin to right wicro-iliac synchondrosig (right mento-pos- 
terior), K. M. 1'. ( mento-dextra-|Hjeterior). 



posirroys of face rnESKXTATioNS. 2G9 

FW. 109. Fw. UO. 









EXCKPTKiNAL. 

8ix pctltloDi of Ikce pretmUtion. 



270 FACE PRESEyTATIONS. 

4. Chiu V* left-s>arr<:>-i!iac synrliouilroaiB (left meulo-iKwU*- 
rior), L. M. F. (mento-la'Vii-pwterior). 

The *iirc<'tly aiiten>-pt*terii»r iMxitiuiij* of i'aoe ]>ret»ciit«li<niK, 
a8 Beeu in Fig& ll*:t and 114, are .so exlrctiiely rare us U> be 

Fio. ns. 




TrATwvenie [losltlon of fkce at suT^erior strftlt. 

almcist never met with in prai-tice. Tlioy are, liowcver, pofj- 
aiblf, ami whou tlicy <tfrur. are JUMHitniiwuijily nuufrte*! into 
ono of the other four pc»ffitions (n'prps<*ntc(l by KitfH. lOi*, 110, 
111, and 112) during the progress uf lalK>r. 



LEFT MENTO-AyTERIOR POSITION: MECBAMSM. 271 



(iVbte, — ^The relative frty^iieney of the peveml (MMtitioiiH has 
not been positiveJv awcrtiuiied, but the nieiit<)-|K»Hterior |iosi- 
tioiiB are more tVeijiu^nl thuu ihe meiiloanterior ones. AVhilo 
the four jHtHUtinm of tlitr face Imve Itet-u nniiu-<l aofoniin^r io 
the sjitno plun ntlopted for the oeriput, it Miay \)v Hlated tliat 
the cbiu is ofteu not ejrai-thj al either uoetuhulum or «iero-iIiuc 
8)'Uchuudrofcfis, but at some point betweeu the two — i. e,, 
nearer the centre of the ilium, nn<l hence the |RiHtions are 
cnllefl in some l>ooks simply right and left mfido-Uiuv, (See 
Fij;. 11/j.) The chin, lu)wever, will arrive at the acetabulum 
or sacroiliac synchoudrosin during the l&lM)r, and the plan we 
have adopted we think is be«l.) 



Frequency of Face PRESEirTATioNS.- 
in about 250 labors. 



-They occur once 



Mechanism of Face Cases. — The whole matter is ea«ily 
understXHxl l>y reuieml>ering tlmt the fhiu is the mechanical 
e<piivnleut of the oi:*ciput, and follows the same merlianical 
movements as the oi-^Mput dixsi in head prest^iiUitJoiiK The 
chin end of the e^p-sha|)e<l head eonit^ tirst. The several 
stages of the mwhanism are: ^. Extension: 2. Descent; 3. 
Rotation : 4. Flexion ; 5. Ke^ititutiou (^external rutaLiou). 

MiXTiiANisM OP Left Mento-anterior PosmoN (Cnra 
TO Left Acetabulum). — 1. ErUmnon^ by which the o<viput 
is tilted up and the chin down, so ai» to pet the lon^- (o j inchefi) 
o<'cipito-mental diameter more or lew? endwise to the plane of 
the i>elvic brim. (See Fijr. 11(>. pa^e 27*2.*) The diameter of 
the child's face that apreef with the obli<jne diametrr t»f the 
iielviK in which it ent:aj;es, is the (Votil«i-nientiil — i.e., the chin 
U4 toward the left acciahulum, the t'orehead toward the rij;ht 
sacro-iliac «ynehoudrt)*)i». 

2. Dt'itcetU (Fimultaneonslr, however, with extennon), by 
which the head {hmt'emlt^ chin first, throu^li the brim, into the 
cavity, down to the indineil plane anil [H^lvic Ihmr. 

8. RatalUm, t»y wliicli the chin ^lidtw alonu the left anterior 
indineil plane, at once, dnwnwiird, forward, and inward toward 
the median line, to the Hvmphysis pubis; the forehwul nu^n- 
while glides along the right |K«teriirr inclined plane to Ui6 
centre of the imicruni. (See Fig. 112.) 



272 



FACE FRESENTATIOSS. 



4, Fi^Tiou. by whioh the chin psoapes under the pubic arch, 
and ri«i** up ouLaide toward llie mons veueris, while Ihe fore- 
head, parietal protul>erHuce8, and occiput successively emerge 
at the perineum (Fig. IIH). 



FlO. 116. 



KlO. 117. 





Anterior rouilun of cblD. 
Fh). lis. 




Inflaonoe of «xt4>nston In pcrmlt- 
iliig desoviit. 



Ddivory by flexion of ohln 0T«r 



6. ReditnHon, by which the chin turns lowurd the raollier'a 
left thi^h (the thi^di corr(^|Mm<ling Uy the nct'trtbubmi at which 
it rtrijriimlly prctn iilc<l ), in (xintH.M|ncitce df HhtiuMcrs rotating^ 
u|x>u the inclined plaueii — lell shoulder tu pubea, right to 
coccyx. 



ta-T MEyrO'POSTKiilOR POSITION: MKCHANISM. 273 



Mechanism in Kigiit Mento-anteriob Position (Chin 
TO Right AttrrABULrM). — I. Eui^imion ; 2. Descent; 3. i?o- 
talion — of chin, aloiifj: ri;:|;ht anterior iufliiieJ |»luue to sym- 
ph}w piiMs; uf tureheiul iiloiig^ lell |K»^teri<)r inclineti pluue 
to sttcruiu. 4. Flexioa of chin iipwunl. towanl nionu vencriB, 
while otriput twuiM* at pf rlneiiiii. .'). Kt-stituliim. chin jftH« 
to rijjht thitrh (tliigli correi<|)<nKlin^ to aceUibiilutn at which it 
i>n>riimlly pn-«'iii*'il), hy reimoii of shoulders rotating — right 
shouliitT to pubtjfl, left to bacruui. 

Mechanibm in Mento-posterior PofliTioNH. — Before 
ilescribiDg th^ae, we may auti<'i|>at« the same Uirteroucea with 
re^ird to rotation and llexioti ad wc found in hejid jircMunbi- 
tion? with regard to rotation and extension ; that is Uy say, in 
the greiit majority of Ciwes, when tlie chin i« dir^'t'ted p<wte- 
riorly, it rotates all the way round to the symphygis pubia. 
In doing so, it, of c^^urso, |«wsee the iu*etabiilum. but it no 
sooner rcarhea the aceljibuluin than it ia in reality an anterior 
[Kwition of the chin, and follows the same nieclianisni txavtly 
as just detieril>e<l for mento-anterior positions. And, again, 
with regard to tlexion when the chin is l>eing l>oru,.it would, 
in niento-p(»8lerior jiosttious, of course, be flexed downward 
over the |>erineuin, instead of vpittird toward the mona 
veneris. 

(A'b/*. — It may here be anticipated, however, that such a 
mode of delivery in face pre^enlatioiw i^ pnicticAlly a mechan- 
ical imp<v«i*ibility. lus will l>e shown presently, and in which, 
therefore, the analogy between head and face presentations 
hitherto apparent, is wanting.) 

Mbchanism in Left Mento-posterior Position (Chin 
TO LErr Sa<'RO-ii.iao 8YNcnoNi>Ro«is. — 1. Ertcimw^; 2. 
Di'weni : -i, Rolatlini .-—in the vutjurity (d' nwea all the way 
round to the syM»phyt*iH pvibis (when the IalM>r will be fininhed 
art in rnentiHinterior (Mjr^itioits) ; in the tiiinontjf of eaM¥t, rotJi- 
tiiMi i»f the chill backward to the sacrum, whrn the mtchnu'tmn 
stofis. and rtnnplriion of delivf^nj i'h mtrfntnlcfifhf iwint}ti*iftfe, 
unlfftf, indeed, the head be unui^uully tinnill and the |M*lvi8 
unusually large-, when ilelivery would («ke pbuv by back- 
ward flexion of the chin down over the perineum. (Hee 
Fig, 120.) 
la 




274 



FACE PnKSEyTATlONS, 



Mechanism in Kuuit MKNTo-rosTEBiOR PosxTiosr (Chin 
TO UiGHT SArKO-iLiAC Sync iii>Ni»K(>HiH). — 1. Ertetntion ; 2. 
Dt^ccnt; 3. liotatiou — iu llie iiiajorit)* uf cubes all iLe w&j 



JTlU. 119. 




\ 



DtagrunmiUc view of mcrhanlont In « right mculo-pni^tvriur piMtHom of a tece 
prri^mtiaUm, ohiit muUiiB tu putwi. 

muiiil to the piihee (and delivery 08 for nit^ntiHUitorior \Hm- 
liotw) ; in tliu minority of oHses roliitiou uf chiu lo iwieTum, 
and conHi-ijiiout arreut uf niechoiiiain, further prugresa t^xjing 
im(>utwible. 



DUONOSrS OF FACE PRESF.NTATfOyS. 



275 



Explanation of Arbest. when Chix Rotatea to 
Hacrum. — It is neoeasiiry for the chin eiui of the ooripito- 
inentJil diameter to encujte oi'er the edtje of llw perineum imiore 
it can possibly execute the movement of downward tiexiou 
ouUide the perineum. Now, as we have seen, the depth of the 
j>osterior wall of the pelvis, fnjm the sacral promontory to the 
tip of the coccyx, is four and a half inchest, while the length 
of the anterior surface of thtf child's neck, from the dvnium to 
the c/iin, w only about one inch atid a half (only just long 
enough to span the depth of the anterior pelvic wall at the 

riu. I'jo. 




ArT«it of mecbAnUm &ft«r pn«t«rlor rotation of cbln. 

pubic ayniphyais) ; henoe after posterior rotation of the chin 
the child's Htcruum impinged ujMjn the pelvic brim at the 
sacral promontory, or i)erhaps l)egius tt) descend a little below 
it, and there 8tn|i6, »> that the chin id thus arresttnl in the 
pelvis while it is yet a good distance higher up than the point 
of the t^occyx, and the chin-pole of the occipito-mental diam- 
eter cannot escape over the [}eriueal border to perform ilex- 
ion. (See Fig. 120.) 



DiAONOflia OF Face Presentation. — The tfide of the face 
(at the l>cjririnin«7 nf lalior) \s the part firpt touched by the 
examiiiin;,; Wu^i'T — that is to gay. in a I* M. A. |ioe»ilion, llie 
left malar iMmc ; in a R M. A. |Htsition, the right malar bone ; 
iu a L. M. r. ixiiiition, the leil malar lK>ne ; and in a R M. 
P. |Mwitinn, the right malar bone. In piissiug the finger 



27») 



FACE PHI^SKNTATIONS. 



hi);her ii|i, uml intire backward, ihc nose may be fell, the 
oiteuin]^ of the uiistrils iiidicaliiig the direttioa of the mouth 
anil (■/(//( ; while tlio ttrbius and forehead will be found in an 
upiMtt'itr direi'tlfin. 

The face may bo mistaken for a bn'och, owin^ to the swollen 
fenliiH-'H rfHeriihliuj^Mlie ^'euilal organs. Diagnosticate by feel- 
inj: the irioiuh. which iit a fi^uri- lM>iiiide<i l)y the hnni ijuina 
of ihp maxillary iM^net^ while the auut {to Ik? felt in breech 
ctthe*<j iw a »(.t\l ela»tic ring. No coccyx-point can be felt, as 
in brwch caws. 

Abiloiiiirml palpatidn in cones where vaginal examination is 
unwilittfactury, owing to the presenting |Mirt being high up and 
dithcnlt to reucli, may iw uA-ful and even uece&Hiry. The 
palpating linger rwogni?*.' iho very round, large jnominence 
of tfir nvrijmt ott that tide of the |)elvic brim (higher or lower 
acconiing to degrw) of dorfccnt into excavation) t4)ward which 
iho chiUfft back in iiirwl4.Ml; the head tumor a]»peara nfinvd 
eitilnly itbtttrut on the other tddc. In head preseutaiion the 
fon'hftid, dirccliHl toward the chiUVn aMometi^ wha the most 
prominent and accetwildo region: diflereuee very apparent 
The l»rei'ch is rtKHignixwl liy its usual charm^terisiics in the 
fundus uleri, ami while the jml|»ating hand niovee downward 
over the hack toward tlu> head, it WhjCvi iiiUt the <Wp dt-pretmon 
or Mvittf l>etwoen tlie back and rtninded |h>1c of the extended 
occiput The small irreguUir ;m)jrr/ui» of the eirtrcmititjni\er 
the anUrior as|RH-t of (he chilil are nn>re eiitily reco^iized than 
in head pre*>ulntinns. (twiiig to the grt^tilrr prt.iniiicnce nf ihe 
abdomen cau.-^^J by tlie ehihl'a ImkIv being bent (mchl'tird, 
iurfead of being tiexed forward lui in hcHil cjii^'R 

In some cases the horse>htx' fliain* o 
Iwue and chin may lx» felt un that ftid 
the 



pntnunent occiput 
rnoeis 



Dittg 



of the 



^mni 



pat 

are 
left. 



ion w Diaoc 



irec 



ttni 



ui 



the cl 
iveli 

Th. 



TRKATMESr OF FACE PRESKyTATIoys. 



277 



hrol congestion (hie to pressure of its neck nntl jiijii^tjlai' veins 

agairiHt the unU'rior pelvif wall ; or itti ftiuia uuiy l>e futully 
eoinpresi*e<i, aflfr ni|jture of the \nv^ of water?*, helween the 
aiitinnr prujfvlinn of the fliilil's altiJoinen und the uterine wall. 

Dnnjjers to mother, such u» may (xrur from any tt<iious 
hilMtr. e^iK-r-iiilly when, in nienttj-posterior poBilions, anterior 
rotation of chin tails to take place. 

Though sponl^uieous delivery is the rule, the mortality to 
l>oth mother and <'lu!d \» Homewhut greater than in head jire- 
sentatious, and a^istanee va more frequently required. 

Treatment of Face Cases. — In mento-awfenor positions, 
g-enerally none, further than <-nrefnlly wat<*hin^ the ca.se for 
symploniH of exhaustion from prolimj.'ed ^'Iforf on the [Mirt of 
the niuther, or of failure on the part of the child, when assist- 
ance umy l>e renderetl hy force|)K, pn»vided the head have 
descendwl into the pelvic cavity. Use of forcejs at the 
Siijurrityr strait \» woi advisable in face cases; {Kxlalic version 
is preferable. 

in all c}UH» avoid rupturing merahrnnes during exandnations 
in early stage, and l>ewarc of injuring the eyes with the finger. 

In inentt>-/«>jr/rr/o/' |K»sitions, endeavor to secure anterior 
rotation of the chin when it fails to take phice spontjineoualy. 
Tlu' si*vi'ral methods of attempting tliis are: I. Press the fore- 
heiul hai'kward an<l ujiwnrd during a pain, so as to make 
extension more <Hmiplete. and thug cause the chin to dip lower 
down and touch the anterior inclined plane njwn which it niny 
glide forward, li. I*nta finger in the mouth, or on the outsiile 
of the lower jaw, and draw the chin forward during a |>ain. 
H. Apply the straight forceps and twist the chin to the puhes. 
4. Apply the vectis. or one hlnde of the force|is. viulrr the 
m<»st jMislcrior cheek, and oirr the antertiir indinetl plane, 
thiitN as it were, thickt-ning the latter, so as to make it reach 
the malar hone and constitute n jntint ifajijmi which the chin 
can toih'h and so gliile forward. 

Should these attempts to secure anterior rotation fftil. an 
eftort may he niade with the hand, vectis, or iillet, to bring 
down the (»rciput ami convert the face into a head presenta- 
tion. 

In order to surfVi.Ml in thin nuuiifuvn* the nieird)rnni'S should 
Ik* nnltrokeit. the tui uteri dilnlrtl. the face not so deeply eD- 




278 



FACE PRKSENTATTONS. 



gaged that it cannot lie lifted to or nl>ove the pelvic brim, and 
an ausesthHJc mliiiini^tered. 

Aj^ain, tUilin«: in this way to produoo nnterior ro(nlion, the 
heiuL if il !»».' "''' («<* "leejtly engajfe<l in the (lelvis, nud have 
not pMssoil tliniii^'li i\iii OS uteri, may lie puHhetl liaiik, and the 
chilfl be tltlivert'd by }nniatic vfrsion^ 

Sliiiubl none of these nietluMls be pnictirnbk* tiud the head 
become inipiuieil in the pelvic with the chin toward thetoicrum, 
the only resitrt ia eran'mtomy. Attempt have been made in these 
casefl to deliver l»y fiinM'iw after hit^^ral incision of tlie peri- 
ueuni, but they can unly succeed when cithiT the child is small 
or the |*tilvia over-larj^e, Usniilly the child'rt life hn^ l»een so 
far imi*rilled by delay and iU coiiseituenres that craniotomy 
may be ilone without compunctiun. Possibly 8ymphy»eotomy 
may prove Ufteful in thetJc cjwch in future. 

In all caneH ^>f fiu*e prcittnitJition special care is necessary to 
avoid rupture of the (terincum. 

Correction of Face Presentation bt External 
Manipulation. — Ktirhj rectification of face pr«*entJition — 
ita conversion into an occipiljil one — by ejrU-rual vianipohttloit, 
has Iwen lately re<*oniinended. It is nvaihible only when mera- 
hrauea are unbroken, alxloniinal walls relaxp<b nntl operntor 
skilful, Ijet ojifc! Imiid. ijver the abdomen, seize the anterior 
shoulder, and lill it, with tlic chest, upward an<l t4)ward the 
child's back* while the other hand, near the fundus, presses 
the breech upward and toward the child's abdomen. When 
the botly is thus lifted the (X'ci|mt will des(%nd, or may be 
ttssistdi so to do by the bntid tif an »>«iKtaiit pressed U]>on it, 
low down, afler which the l)rce<'h is pushed directly doiniivard 
and Hcxion rendernl ]>erfect. 

The aiMiexeil illnstraiiuns. mcwlifietl from Lusk'fl reprtKluc- 
tion of St'hntz's iliajrrams (sec F\^. 121 ), explain the method 
more exactly. The arrows indi(i«te the direction in winch 
pressure is apiilietl to the several parts during succei«ive steps 
of the o|)eratioi». 

Another plan: Let one hand press foxternally, of course), 
upon the projecting sternum of the chihl, p\»i»hing: it toward 
the chibrs spine, and wmicwhat upward toward the fundus 
uteri, while tlie other hand (externally) presses the occiput in 
the other direction, vi/«. downward and forward toward the 
anterior surface of the child's Ixxly, thus bringing the chin to 



BROW PRESEyTATIONS, 



279 



the chest, which is ilexion, antl presentation of the occiput 
result& 

AguiD : tliet<e nmnipulations can be carrieti on hy ot«« oper- 
ator cjrtrr»aUyy while the finders or hand of nnuthrr iLsni.si in 
flexing the ha&A by mauiptihitiug, per vaginant, iuteruully. 



Fn;. 121. 




8cli«tz'ii method uf recti ficitUou by exl«rtwl maaipulatluu. 

Finally, let the youn^ pra<rtilii»ner especially remetnlter that 
the great majority of far-e cuM^i will l>e dnlivertMl without 
amiatance or interferent'e, provided all other (Y>nditions are 
normal. 



Brow Prfskntationb. — A rare prceentation Cof the 
"brow** or furt'head ) intermediate between a head and a fafc. 
It tM'4'nrft in this way : liux^ ]in«entations are deviiitioiiH from 
head presentations — that is, in face presentations the head 
ori^nally presented, bnt the occiput catching on the ride of 
the brim, lodgwl there, while the chin was fon^ed down, con- 
stituting face prei*entatii»n ; but in this process of conversion 
t»f a head into a face, arrest may take pla<'!» half-way lietween 
the two, when, of cour»*e, the toreliead will be made to apjiear 
and Hlop at the centre of the Hn|M'rior i*trnit : this is a brow 
presentation. The duitjnogiji may l»e made out by the |Hjeition 
of the Inrtje anterior fontaiirllo and itii radiatin^r sutures, the 
proiuiueuce of the forehead, the orbits, and parietal boneo. 



280 BREKCn, KNEE, AND FOOT PRESENTATIONS, 

Trfattnmt consists in converting the '* brow " iuto either h 
htuwi ur iiico ])rt!f^iMiial.ioii, by pro<iiK'iiip. re*>pwtively. complete 
rtcxiou or ctiinplt'tt; t'xtfiisinii, |iretV'rnItly iho foruitr, hy juish- 
iiij; tip the lori'liciKl. and ftrin>:iii^ dowti ihc itcLipul. In ninny 
nit^v it tuki'*J j)Ia<T htMitilant4>iii«ly. 

MiiiH[iiilaliitiiH ihr lliin purpitsi' nmy hv eUhfr external or 
iiit^^niiil or hnlh i'<iiiji)inily. iw jui-l sUilrd for face prt^t'uUi- 
tjoiis. Two Jinf^tTs nmy 1»C' intr«Miureil inl<i the cliildV mouth 
nnd tniction rnmU' on tlie Atip^rior maxilla to protluc;*? exten- 
sion auti convert th« brow int<j u face presentation. 

Podalic vertsioii has l>een ri**"«inmieinie<i when the diapntKriis 
ie made early ; it should he liiMitetl to eases witi» a etiiitnicted 
conjugate diameter, ur where ttjK.'edy delivery is re^iuired to 
save mother or ehihl. 

When llie brow presenlntion has l)een chanee*!, by manip- 
uhjtion, into a head or f'ae^, but revrrtj* to its M position, for- 
cejis may lie employe<.l to prevent this reversion, iw well ae to 
hasten delivery by traction. 

In mento-posterior poAUioiis of a l)row prtwuUUion the Ktime 
didiinihits may occur, when the «it*e is chanj^ed into a face, as 
in fa<"e presentation, hetuv every effort must In* made to rotate 
the t'hin lo tin' |uj1k»h. 

When all other niensnres fail craniotomy may become a 
la^t Tfiiort^ and i^lniuld ivrttiiidy Iw an early one when the 
child is dc'tiii f<)r the nn>iht'r's 8iike. 

As in face cjisen, it is jxiesihle the future may demonstrate 
the utility of symphyseotomy in ditHcult brow presentations. 



CHAPTER XVI 



BREECH, KNEE, AND FOOT I'RESENTATIONB. 



Breech Pr!C8Evtationh.^ — Thene oc4'ur once in about fifty 
labors f2 \^t cent,). The ptdvic end of tlie foetal ovoid pre- 
sents, the lower linil)w l>einp flexed ti]Hm the alxlomen, m that 
the buttocks first enter the [xdvir brim. IVually the leps are 
flexed upon the thighs, as shown in Figs. 122 to 127, excep- 



282 BnEECH, KNEE, AND FOOT PRESENTATIONS, 

tionally they are exUnnle<I ftt full lenpfth, so that the feet 
approiifh the fiu'e or fioiiit over the uliouhiers, (St»e Fig. 128, 
1>. 2H2. and Fig. 129. p. 284.) 

Positions of a HRKErn PiiESENTATioy, — Of iliese there 
nre four ; nnti the given |x»int tui the breeeli, from wliich they 
are oamed, is the child's mcrunu Exceptionally the cbild*B 

rw.iaBk 




Breech prMpntalion— lt>|[K fxtunded. 

sacrum may he directly in front or liebind, really making six 
pottilioiia Thus : 

1. Sacrum to letl acetiihulum (left sacro-anterior), L. S. A. 
— Bacr<)-Ia?va-aiiterior. 

2. 8iic*ruiu to rifrht acetaliuluni (right aacro-anterior). R 8. 
A. — tMicnMlextrn-anlerior. 

3. Sa<'rum to left 8acn>iliac ffyncbondnwis (left sacro-poB- 
lerior), L. S, I*. — sHcro-heva-jKisterior. 

4. Sacrum tn rijjht nacro-iliac t^yiichondroeis (right aacro- 
poeterior), R. S. 1\ — BacrtMlextm-prjpterior. 

The two mero-anierior poeitions are nioet frequenL 



LEFT SACnO-ANTERIOR POSITION: MECHANISM. 283 

MFXiiAViaH OF Breech Ca8e& — In complete delivery of 
the rhil<l tiicre are here three 8ucr««ive stages to be consid- 
ered^ viz. : 

1. MlH■huln^'tu of the l)reH'l>. 

'2. Mechniiisin of tlu' phouldfrs. 

3. Mecbaniflm of the heatl. 



Each of these may ugaiu be suUlivided aa follows 



Moulding, 

Deficeut, 

Rotation, and^j./, yf^cy. 

Delivery oj the breech 

Deeoent, 

Rotation, and 



g. Delivery of the ehouldtra. 

h. Flexion, 

t. Descent, 

j. Rotation, and 

k Delivery of the head. 



Mechanism in LeftSacro-anterior PofiiTiojj (Sacritm 
TO LKtT A<KTABlTLrM). — Here the longwit diameter of the 
breech, viz., from one Inx-httuter to the other, o<Tuj)ie« that 
oblique diameter of the brim which extends from the riyht 
acelaJuilum to the frjl sacro-iliac HynchondrosiB. The wicnim 
of the chihl being dire<-te<l toward the left acetahuhim, its 
back, and, of course, the back of its head (iK'ci|»ut) are din-cttMl 
toward the left aut^^rior part of the uterus, in a line with the 
left acetabulum ; hence, when the body is delivered the orciput 
of the afO^r-rmning head irUl a/jito lie directed fo the left acelabit- 
lnm. As lal>or pro^Te^ses there tnrcur : 

1. Mouldititf of the breech, by which it simply becomes grati- 
ually compreN»e<l ("moulde*!") into a circular shajn^ s<> that 
it nuiy pass through the iis uteri and |k'lvic brim. 

2. Drttrrnt. — The breech {Hissing down the [)elvie cavity to 
the pelvic Ho<>r. 

S. Hotatiojt. — The left hip (the hip nearest the pubes) glides 
along the right anterior inclinwl plane to the pubic symphysis; 
while the right hip (the hip ncari'**t ihc sacrum > glides along 
the letl (Kjstcrior inclined plane to the sacrum. The long 
(bi-lrf»chan(eric) diameter of the bret^'h, which cnlere*! the 
brim in the oblique [lelvic diiinieter. Iins now. tlieref<»re, he- 
ntme parallel with the longest twnten>-|Hwterior) diameter of 
the inferior straiL (^8ee Fig. \2\^.) 




284 BREECH, KNEE, AND FOOT PEESENTATTONSi 

4. Delivery of the br«?oh — the hip that w toward the piihes 
fixing itself against the arch, while tite other cue sweeps 
ruuiid the curve of the (maternal) sacrum and comee out firet 
at the {>enneuiii. 

(Notf^ — It should a;^{iiii he ol»s*Tved lliut (ir.trfjtt ntHvssarily 
occurs ifimuftanfuiiithf with and ituriiig nil tlif other HtJijj;t«, 
So the shouhlers and head have, of course, been aimultaneoiuly 

7ia. 129. 




Rotation and dellTery of hips. This figure roprvwnts the legs odatded, which 

!■ nouaua]. 



[eeoendin^ with the hreerh. Dtwent \s considpre<l rb a sep- 
^ftrate stape only in ho far as it in a net-eaenry preliminary of 
rotation — i. «,, the descendiujr |>art mu-nl anm^ ilotm low ennU|jrh 
to strike the inrlhayi phncji and pewic fl<x)r l)efore notation 
can occur. 

Note further, tlmt wheu the hreci'h ia extrude<l the «'hild's 
l>o<ly haa nooe«Mirily iKKXinie iK-nt tm it« mle oonfomnihly to 
the curve of the pelvic canal. Somctiniee thin is inipnt|ierly 
set down as a separate stage of mechauisni, called '* lateral 
flexion.") 



LEFT SACnO-ANTERWR POSITION: MECffANISM, 285 

To reeuiiie^ the brewh having l>een delivered, we have next 
to deal with the shouldtT!?, thus : 

r». Jkif'vitt. — Thu loiijrest (hisiit'roiuial) diameter, entering 
the hriin at Ihe «ime ohliijue dianu'tt-r as the hi-tnK'hanteric 
diaiiiL'ter of thu hrctvh did, dettc^Mids to the |>clviL' Hmtr. 

(i. Rotation, — The shoulder iiturt*.t ihe [>uht?> (U-fl one) 
n>Uit4's to tlif puhcw: the shoiihier iieares^t the wicruiii (ri^ht 
oae) roUitt^ tu the waTuni (tiee Fig. 130). whioii hrin;.'» the 
biaaLToruial iliunieter autc^ro-injaterior at the itderior fctraiu 

FiQ. 130. 




HiiUUoii or atiouMvr»: Ihcir lone (blMcrouilul) illttiucUir in Uuc wiiti long 
(anient- |M«U!riur> dlaniutvr of uullet. 



7. Delivrnf of thr Ahoiddrrs — the one toward the piihcH fixing? 
itM^ir tliere, while the other one iiwee|Jt!t round the curve of the 
aucTiiin, and «'*ttnes ut lirnt at the jierineuuu (8ee V\t!:. 131.) 

The Hhoulders having been dcHvere*!, next e<mu« the head, 
thtiB : 

H. Flcriuii, hy whh'h the rhin-|x>le of thn <Mvi|)ilo-ineiilal 
diaintrter m made U> dip duwu tuwurvl the ehild'd 8teruum, 




286 BREECH, KNEE, AND FOOT PJlESES'TATrom, 

while the occipital {>ole ia tilted up toward tbo fiinduH uteri, 
thua plotdng the occipito-meutal diameter mure or iuttt eudwise 

Fro. ISL 




Delivery of luwer shuuldur llrst, iiL tliu |>criuL-um. (lii Fin. 13(t ix^ciputlsto 
Ihu Ivfl; nj/AJsh>iiitder will cnint* flret itl pt;riiivum. lu Fig. Ul occiput Is ID 
thu right, and Iffl sbauldur oumes uul first m pcriDL'tun.} 

FlU. ISZ. 




Anterior roUtlon of occlpnt. 



LEFT SACnOPOSTERrOR POSITION: MECHANISM. 287 

and panillel with the uxis n\' the |)elvis. The (xriput is 
biwanl tlu- It-fr areUtlmluni iuu\ iho (ort^-lieml U)war<l the ri^hl 
Hiwro-iliac ^yui-hoiHlrosi.-^ ; hi^iuf the o<x'i|)itu-l'rontiil diameter 
occupi«t an ohlisjui' dianiH4?r at the lirim. 

9. De^tui of thi' liead iutu the |»©lvic cavity, until (X^put 
strikes left uuterior inolinetl plane. 

10. Rotation — of wriput to pulMjg — of forehead aud face 
to hollow of sarrum, thus bnt);^iiij^ tougest eogaging diuniet4.^r 
uf heuil anten^-|Htt4U'rior at the oulleL (See Fig. 11^2, page 
286.) 

11. DflitTrt/ of head — the otrciput fixing itself hfhind the 
piihie mjmphyytt^ the Imek oftlie chilli's neck uudrr tlio pubic 
arclu, while the chin eseajjt-s liryt at |»eriiieuni, followed sue- 
oewively by mouth, mwe, forehead, biparietal e<|uator, aixl Iai*t 
of all the oeciput it^lf, which sweepe aloug the curve of 
sncnini. 

Me<^iiani8M in Right Sacro-antertor Position (Sac- 
rum TO KlOHT ArETABrUTM). — Monhiintj, tieMcnit, and rotor 
Hon of the breech. The hip aeareat the piilwd rotating to the 
pubee, the one ue^irenl tlie .sacrum to the wurum. iJvlirenf of 
the breech — the hip nearest tiie sacrum coming out first at the 
perineum. 

Deacvnl and rotation of the shoulden) — the ehoulder nearest 
tlie pul>es rotating to the pulies, the one nearest the sacrum to 
the BiuTum. Lkiivrnj of liie slioulders — the one at the isacruni 
con»ing out first over the |>erineum. 

Ffi-rioiu (tcAf'^'nt^ and rotatum of the head — the occiput (now 
at the right aeetabtduni) rutiiting t>ii the right anterior in- 
ciiuetl |>laue to the nubcis the foreheail U) the ttacniiu. Drfh^ 
t*fy vf thr head — clnn, mouth, norit5. forehea^l, l)i[«irielal etjua- 
tor, and \a»i\y 0(*ciput, suoccHtdvely eecnping over ])eriueutu. 

Mechanism in I^eft Sacropohterior Position (Sac-rum 
in Lnrr SAi*u<»-iiJAt'SvN('H(i\i>U(»HiH). — Moulding, de«'ent, 
rtitAtion, and delivery of the bn'**eh ; and dewent, n»(atjnn, 
and delivery of the shonldern exactly as alrcatly iies*cril»e*l for 
'tntrrior (KtHitiimK of the «ierum. 

Flexion and ih-went of flie head are al.>4) the siune, *'.trrjtt 
that the tH'eipulenlers the |K.'lvi»> (linrlrd toward the leil E*iuiro- 
iliac syucJHMKlrotfitf iiwteaxl uf toward one of the aoetabula. 



288 BREKCH, KNEE, AND POOT PRESENTATIONS, 

Hence rotaiion of the occiput takes place, in the majority of 
uOCMes, all the way roinid to the HyniphyHis piihiH, when the rest 
of the mechauisni is tlie same a* just ilescrilnwl tor anterior 
poeiliuns of the occiput In the. mltwrtty of auf* the ooiMput 
rotates [Mwu^riorly iuto the hollow of the sacruni, the forehead 
to the puhcft. 

Ih'iivtnj of tilt! haul now takes place (moet ofteu) by ron- 
tinued ficxioiv^ the ohin-|>ole of the ocdpito-iueutal diameter 

Fltt. isi 




roflterior rotntlou of occiput and delivery bjr flcxloa. 



dips toward the child's Hteniuiii (umhr the pubic arch), while 
the ocdput is tilted up posteriorly toward the wicral proin- 
Dutory. The rm\x^. of the child's iiw^k rest*i on the |H'riiiciim, 
while chill, mouth, now, forehead, hiparietul wpiiUor, and 
laMly neciptiU succojiively t-M'Uiie t/m/orthe puhic arch. (See 
Fij?. 13o. ) The ti^Mirc in foliit lines shows the direction iu 
which the UmIv nui.-it Ik- held. 

Delivery of tlie la-ad may also take phice (but very rarely) 
by continued txtenynni. Thus, the chin-jx>le (►f the oecipito- 
xueutal diameter, insti'ad of iK'inp dcprtwH'il umicr the pubic 
arch, ^wiiit-* up ultovt the pubic symphysis — in fact, towani 
the woman's bladder. The antrnor surface nf the ehihTs 
ueck is fixed against the jMtnttrior asjKKt of the symphysis 
pubiA, while the (Kripilal pub* of the ooi>ipiU»-mental diameter 



RIGHT SACRO-POSTERruR POSITION: MECHANISM. 280 

is fon^ecl Jowu aloug the hollow of the sacrum to the cwryx, 
a!nl ti«ni(K!S Hrt't at the j>pnneum, tbllowcHl siicceaHively by bi- 
jmr'u'tal iNjualor, Ioii'Ik-iuI, iiom*, tiiDUth, nn*\, hi**t ut* all, the 
cliiu iti*elt*. l^See Fig, 134.) The Ixnly u» \m \w\\\ up toward 
the pubtiS. 

Fig. 151. 




PMUcrtor routlon of occiput «ud delivery tij extonslon. 



MErilAM^M IV UlOnT SAt'RO-POflTERIOR Pl^SITION (SA- 
CRUM TO Kkuit Sa(r«>-ilia(: Synciionhrosis), — Tlie firtft 
|>art« of the hil)or ure the same a» just Jcwrilte*! for the Irjt 
Ka4'n>-]M»U'rior |Mwitiiui. Wheu the breech an*l shouiders are 
<lelivere*l, llie wviput i«, uf cour!»e, (iireele<l to the ripht 
saen)-iliiu* Pvin'hroinirfM*!H. In the majority of eaw« it rotates 
all the way rouiul to the pubee, and so bccomee an anterior 
fK>>itiou. In the minority of cases it rotates to the Ha4-runi. 
and will then l»e delivered either by ct/tUhttUfi ftfAofi^ the rhin 
ewtipinjir first under the pubi*' arch, or by fontinttetl ertruHioii, 
the occiput ec»capiuf? first nt the pcnneum, as just dew'ribeil 
for the I-.. S. P. |x*ition. Casea in which |Xt**lerior rotjilion 
(rt' the after-i-oniinjr hew^l tKVurs coniprise a very frnaff minority ; 
MK-U rotation w extremely run-, juid will Hcldom Im; »*een in 
iirdinury practice. 

{Nfftt. — Sonietiniei' in HJicro-yviwr/rrmr jM»Hilinnifof the bree4.'h, 
the rutatiou widch briiit'>> the anterior hip to the puhes 'jotg 
itf 



290 DHEECn, KNEE, ANT) FOOT PBESENTATrONS, 



on further, so oa to bring the rhi]d'.s Itacfc to the piilie**, or the 
ba<*k conjps to the puhes !)y continualion of the shoulder 
n;tutiou. In thiH way (he (xriput is broui^^ht iu front to the 
acetabulum before its desceut to the i»elvio Hoor. It has be- 
come oeeipito-auterior.) 

>fi:(iiAM.sM OK Knek ani> Footi.inc. ('ase8. — Theae do 
not rc'iiuii-e sejHirule study. The feet nntl kiieist ure «niall 
t'iif»ii|rli to pjiKs tliroufrli the pelvis without tiuy !*[M?(.'ial mech- 
aiiisni. The breeeh uiul otlier purtt* folhjwin;^ Ihem undergo 
the 8ume movements 02^ in original breetdi cufK«i. 

Causes. — Hydnjee[dmlic enlargement of the cranium ^ pe!- 
vir narrowing ; plaifutu prioviii ; |>i>iyhydruinnios ; small size 
of the child, or it."- luMii^r dt-iul ; inulti|fle |jn*^minry ; [)retnature 
delivery ; uterine tunmrH interferiti;:: witli uf-iial attitude of 
chih], Hrewh pre»ent;Lli'>u may orenr re[K?utefUy iu thesume 
wotuan, as might b expecte<l in eaifcs of j>elviu narrowing, 
or iu iluwe with uteri detbmied by tnniora. 

Diagnosis of the BREF.rn. — The examining finger first 
touches the «ide of tlie anterior buttock (the (me directetl 
toward llie pul>es). and feels the trurhanter r-nvere<l by mu»- 
cles, etc.. wliit'h mnke it Hotter than the hunl globe of a head 
presenUUion. The li.-^ure iK^tween the nates*, the genital 
organs, the anus, ihe pnbaldc prcnenre of nie*x>nium (thick 
and undiluted with lif]uor aiunii), llit- tip of the cim^-cvx, and 
spinous pnK'ei** of sai-rum, are sturticiently characteristic. 
ScTotum iu males .HoinetimeH sw\dleu and ^edematous, resem- 
bling |K)lypus or tuniur, but is less «>lid. Difficult)- in early 
stage, owing to height f pretHMiting part. Bag of waters 
may he large or |>rotrude as ehmgaled sjic. Heware of mis- 
taking fietal vulva for axilla, and fat f»ild of ellM>w for fissure 
of nates.' Ellww hn? three Imny projections (olecranon and 
two humeral con«lyIe?i). Diagnosis from face <9ee faee cases, 
p. 276). Diagnosis of the *' pottitifm '* of a breech '^ prewttr 
tatioit*' may be determined by the direction of the fiwure 
botwr-en the nates and bv the tip of the ft)c<'yx, which alwayd 
points forward toward the pulies of the child. 

1 Owing Icj ttie ftUltude U the child, and Ibe andcvelopol conillUon of It* 
Siut«al uiaacl«8, tbaro Is realty liUle or no/Untrf twtweca the umtca. 



mAnyosis OF the breech. 



291 



When the presk»nling jjert is too high up to he touched 
RRtii»f)U't^)rily per ttir^ituim — ha will oilvn hap|H»u eHrly iu 
InWir, or hefore its iM'piniiin^ — diagnniiiti nuiy lie made by 
aUdtnnirnil pn/jnifiitii. J'jirly in lultor tlie Ijreech will in? at 
or al'ove the [)elvirr hriin ; it tteicr ^UsremU at IIiih fintt, us the 
head sometimes does ; Ihtx-c* pnlfrntiug tinger-enda, entering 



Fio. i«. 






/ /■■ 




I.. ^ 



PUfrnnt^U of pelvic pretteiiiHtlon by pnlpAilon. (After I'arvik.) 



the hrim behind puhic rami, find fxratntion nnpftj. Tumor 
of breech (not oAen reiitnil, hut usually niore towurd one or 
other iliiif fliswO treli* miftrr, vturr irmjitinr, and moif rohtmi' 
lutii'^ than jL'hitH* ot* head. ItcfiHlin^ phitic nt* hack in nmlinn- 
mtfi with hreech iVotii ht'li>w, wliMr almvr the (in;r< r> sink into 
elHKtic dfpr»4f>iou hetwtnMi irunk and head, lleatl dittcuvered 



202 BRKEVU, KSEE, AyV FOOT PRESfCM'ATI0y'& 

iti fuiulns uU-rt uf^ually more on that siile opp(M*]te to the 
iliac fosfia toward which ihe hrtt^.-h lie**. Head may \w con- 
cealeti under liver, or behind t'nlse rihs, and hence difficult 
to |wii]iiite, esfKK'ialty iu jiritiiijiune, in \\\\um the child la apt 
to lie inure verlit-ally ( h'Sfi uhlicjiie) than in nuihi|iiine. Mead 
may be made more /tfifjmhfr by (ir«^fiin<: hreeeh more toward 
the iliac tij^sa, which hriii).^ the head mure within reach on 
the r>p|iofiite side of the Fundus. (See Fi;^^ KJi).) 

In fullowiii^' reHii*lin|: phiue of hack it will be found to curve 
over alK>ve the umbiiicuH toward the side where the head liee. 
The latter may S4.»metinieci I»e made to move by itnlhitivg. In 
sacTCt-jXMitfrior |K>SiitioDS the breech tumor will nearly always 
be aeeompanie*! hv th^ movable jntwit pari-i. In wiero-ziH/mor 
poeitious the breech will ranltf be acctmipanied with Bmall 
parts. The small piirl^^ and interveninjc elastic s|»aces filled 
with lifjuor amnii will uHually be found on the bide of the 
uterui* rppusite the cbihrfl back. In t^vro-fHutterior |xjditioDS 
the hiicrai u.s[)t»ct of the childV trunk will l>e more easily 
reeogniited than the back itself, (See Figs. 122, ]*23, 124. and 
125» iu which, however, the child's body should have been 
placed more uili<ittily — the bre-.-ch more over the iliac fo8«a, 
the head further toward the op|>osite side.) 

Diagnosis of Knee. — Chiefly by exclusion. Ry its large 
size ; by the tibial spine and ]>utella. Frjm a shoulder by 
the abKMKv of ribe and inlep-oetal spaces, etc. From an 
elbow, by the fitil patella — very ditfereiit from the pointed 
olecranon. 

DiAGNOsiH OF F<K)T. — By the projecting heel. Fn)m a 
Imnd by the (inj^ers beinj: longer than the toe*. The great 
toe is longer than the other? — the thumb shorter than the 
fingers. The fingers can Ix? easily sK'parated ; the toes wmnot. 
The foot is placed at right angles (o the leg ; the hand is in a 
line with the arm. The fo<>t is thicker aud not so Hat as the 
band. Its inner lH)rder thicker than its outer one — not s« the 
hand. When. l>efore rupture (d* the membranes, the foot ia 
tout-bed by the obstetrician's finger, it will u.«ually be drawn 
up with a ijuick jerking movement, wliile the hand, under 
like circumstances, will move away slowly, if at all. or, if the 
membranes be rupture*!, grasp the examining finger. 



■ 




TREATMFXT OF UHKECH CASF^. 293 

pROUNOJSia UK liREEcii (_'A8E». — CitnitTully favorable lo 
moLher, though ial»or may l>e long; but liiingerous lo child. 
When IxMiy is delivered utid heiul reuiiued, child dies from 
Buffocittion tlue lo preissure on umbilical c<>ni or to partial 
seimnition or coinprc^itm of pluceiita. Danger greater iu 
footling than breech caae, l>eciiiiHe small feet do not dilate o8 
uteri suihciL-ntlv to |>eriiiit easy |»a>waf:e of after-coming head, 
hence delay is longer after expulsion of Inxly than occurs iu 
breech eases. Lialtility to prolap!4e of funis. In cases where 
legs are extended along front of cliihl. lalwir may be long and 
difiicult The limbs act like »p\ i n lA^ preventing that late ral 
flexion of the Ixtdy by wliich the Tatter is conformed to tHR"" 
curve of the axis <»f the pelvic canal. In diflicult cases, diild 
liable to injury from ]imni[tulations during delivery, hence 
fracture or dihi(M"jition of humerus and femur; injury to epiual 
column or spinal •*ord by traction »»n trunk ; lem|)orary 
|mralysi.« from prc-wuri' on lirachial plexxis ; hemorrhage into 
muw-'les and cellular tissue of neck, es[>eciaih' buumutoma of 
BterDO-mastoid muscle. 

Trkatmknt of Hrkech Ca^^rs. — Do nothing until the 
birth of the breech.' Prf^:*erve mcnibnuu^ from rupture. 
Refrain fiom attempting lo hasten matters by ^Irawing down 
the feet It produces diHplacement of the arms alwive the 
head, and also extension of the iK'ciput D(day during early 
stages of lnl>or is not. dangerous, hut prepares the |>art8, by 
prolonged dilatation, for Bul)8e<^|uent c^v iHUsage of after- 
coming head. Delay of latter U fatal to child. 

When the breech is born, pp-iniote lateral flexion of Ixxly 
by prfc-tfure on |>erineum. When trunk is delivered, receive, 
sup|M)rt and wrap it in warm cloth, (iently pull down a 
loop of the cord, and place it toward that part of the pelvis 
where it will Ive Icsh liable to prc^ure, vi/.. : toward that ?aiTo- 
iliac synchoudroHis io which the childV alKloinen is dirw:te<l ; 
but waste no time in doing this. Feel pulsations in cord ; 
their feebleness proi'laims danger to child. Hold the bo<iy io 
euch a manner as itot to im|M<dr n>tation of tijioulders into 
Bnt4*ni-poHlcrior diameter oi' outlet- When shoulders are 

' It hni ^wwn rrronlly n-fom mended In perform rephnltr vepslnn hy external 
ntnitlhtUuUuit. early, bctaru rupture of mL-uibmnc*, to KVerl Muluuquent ilutgvr 




294 BliKKCU, KKEE, A^D FOOT PBESENTATWSS, 



bora, direct luu^k of child to pui»ic ^ymphyBiH, thus promoting 
anterior rotulion of ocriput. Duriiij^ hirlh of head lift body 
toward moti8 vt'iuTis.' 

\i\ the rute ca«* wiiere loj/iil fftotihvfnuit delivery of the 
head follows extrusion of tnink^ no further at-llve interference 
is De(%3sary. 

But mpul tpotitancous delivery of atter-ooming hea<i la ex- 
cepdonnl. Delay 18 fatal ; judicious a^iHlunce harmlesB. If 
the Hhoulders he not readily extruded, first oue (that at |)eri- 
ueuin) and theu the other nni.st l>e drawn out hy the finger 
hooke<J over the ellww or atnmiion procew of the shoulder, 
elrvitting the breech while withdrawn tijr the /wj-tf^nV)/- shoulder 
— dej}rc»iiing it toward the j)erineuni while ^eltin^ out the 
pubic one. For varionn niethr^la of deliveriujr the aniwi in 
diflerent auff^^ see Chapter Will., on "VcmoiK" 

The meaiii* for rapid delivery of head when it has tIej*cen<M 
to the inferior t(trai(. and (M'ci]>ut hari rotjited to the pul>es, 
are: Ergot (hy]XKlenni^ally if the c;we Iw urgent); manual 
prepare of fundus uteri through the abdomen by a fkille<l 
a^ifitant previouHly securest : urging the woman to hear down 
during the pains with all the volnntjiry cHort >*he can com- 
mand ; and traction judiciously njiplitil thus: .•.tipj)ort ImxIv 
in left hund, one or two Hiigt-rs of which nuiy Ik- pjiNsefJ in 
alon^ |)osterior vaginal wall to tdiildV month (or to uii[)er 
jaw-Uine, one finger being on each side of tlie nose), atid its 
chin de|>r<;sseil toward it* chest, wliile two fingers of the right 
hand are passed in under pubii* arcli and pressed upon the 
occiput Hj aw to tilt it up and axs/Vi/ Hvxioit. (See Fig. 130. p. 
295.) Thus, dnrin;^: tniction, the cnin-pjle of oi'cipito-inental 
diameter is maile In es<*a|)e tiver |ienneum, and ilclivery fol- 
lows. The finjrcr *or two of them) of lefl linnd may also 
lie jtasseil into rectum and niiide to jircss lliron;rh the recto- 
vaginal wall u|N>n the forehead or malar boneas thusagaiu pro- 
moting fit'sion. 

Another methmL Seize (he feel with the right hand, and 
hook the leil hand over the battk of the neck (Fig. 137). 

1 An iininninl hhvuicc wninnii ut (lit.' wimkIm, Htiilini; tlic ImxIv •■( Iht rlillil I'x- 
truilLnl. WiiuUI Ml limy \»> i>r«'ifuiin'ili. in n nunultfl spirit .it i-l luvt**- 

tlKiltlnu, ^yt tht tMnty'uiinitf'i nf^r ftfv.,un .p/i./..mrn, thus < -. : - "H ihr 

fuuiiitu Utl'ri, MIlJ nnitiiiij hnrHiti ill It \*«JtO ItnmiOlf '!'■ ' h.' li'-'Ud. 

Ilonci* It K Intfn.'stlni' in iibk.i.Tvi' ilmt t>ie iiifthfids nf rvcii-m-ir hiac uricun- 
»4'l"'i».ly f*ill*iw<r«I thf t»i*rliliig r.r Niiturf'K Hchool t«> the untutured wivagf— A 
svnl tir <i(iiit:lliiii nul tu ba disd&lncd. 



TREATMENT OF BREECH CASES. 



295 



Traction on the legs w now made in u Uirwtiun nlnwM ui rifjlit 
on(f/in to (he pubf/ff so that tlie I'wsirstance of |iubU' JKUuti, im- 
pinging apiiuHt occiput, pushes^ it up. wliile i:\nu and litce 
dex ami dcscoiul alon^ sacrum, escaping ut [itriiicum. The 
lett liaud t-twulics tli« head, prevents ibs tiK* HUtlden escape, 
and bIko aasistJ* the right in making lracti(jn. The liniid of 
an aJisL^tant, prcsssing upon fundus uteri, will expedite the pro- 
ceee, as in the tintt method dct^cribed. 



Fiu. 13€. 




Extraction of hcii<l In brcceh cues. 

In cflses of sm'ro-jMigtfrior poAitiuus where anterior rotation 
of occiput has failed to »K*cnr, tieprcss the ho<ly toward peri- 
neum. pasH one or two finpers under pnhes to that temple or 
Hide of the face directeii anieriorly. antl prosn it rnund toward 
the wuTum. Face c«nnot he font'd round to jiacrum by tuift- 
ing hofhi wltlutut dan;;er to childV neck. 

Should ihin proceedinjr fail. an<l the occiput */i7/ rrinmin 
pojtteriur, the heatl nniHt he ilelivered in one of two \v11y3, 
viz.: If the head l»e Jleifd with the chin btlotv the puhio 
nrch, traction nuist he made dirwtly {tmcnicttrd ; that w to 



296 HREECIf, KSEE, AND FOOT PRESENTATIONS. 



aay, the wonmn beinp uymn her hark, with her hi[« over the 
fn\'/,t'- "t* the lird. mnkr- traction im th»* IkhIv vfrticnlly (/»«•» 
toward the Hoor ; aiii thi!< hy su^jrajmhic external pressure. 



Fia. 137 




Mjumal extraction of aftur-comlng head. (From iJALABnr.) 

aD(l ouc or twu (iu^i'rs may be piL**cil into rt'i-tuin, punhing np 
the (Mx'ipitiil fMjle, while external hainl presses tlotni the fore- 
head, thus SBuuriiig vumplfir ftt^riou — the proper nieehanism 
fur delivery. 

The other way is by ^xUnunon. Now the chiii is ahox^e in- 
stead of below pubrs. Trartioti on body mui*t be made 
verticiilly ttpuutni — t'lwnrd tin* ceiling iiisteftfl of the floor — 
while the hand on abdomen makes pressure downward and 
backward u|Hin the chin. One or two tiuirers paused far into 
the rei'tum may assiHt extension and extraction by pressing 
occiput forward toward pulkw. 

When manual delivery fails, forceps may i>e applicii U) the 
ai>?r-<*ominf; head. (See Chapter XVJII.) 



TnEATMKST OF BREECIf CASES. 



297 



Kttrm'ilon ir/xni aflj-r-riyinttig hrnH Ia ai ftnjtennr strait, — 
Pressure on tlie tunduj* uteri from rt^M>vt<, ami trrtrtkm on the 
feet an<l shoulilers in litif with nxia of phine of MufM'rior itfrait, 
may firyl \w trie<l. Wiu-ii the wtunan m on her hack und 
bruujirht to the e<l]j:e "f the IhhI, the tnuilon shouhl \n^ almost 
tliret'tiy (hnvnnnnl towanl the eotwx ; and the muuuiil 
pressure un the alKlumen from al>ove should be chietly on the 

Fie. 13S. 



Arreil of bend at itiperlur straU : meUiod of dcUrerf. (WixcKCt..) 

frmital |»oIe of the he«d ^^ secure flexion. When an asKintant 
» preiK'ut lo iimkc iihdoininal pr€*tt*ur<'. the olwtetriciun nmy 
draw un the shr)i]hlers with one hantl, whih- two tinkers of 
the other are |>a£i)tHl up into the eliihrs tnouth and trniiioii 
mii<le on the jaw. Thus three ex]>edioni.M art simultaueouHly, 
viz., (Mttmiuitl jrrr^urf\ nUnuUier (rnrtion* and jniv trnrtiot^, 
(See Fi|;. X'^K) Should these fail, forcejifl may lit- u***mI in 
briui^ the heiwl iulu the [telvit eavity. Fori^ijs arc also ad- 



298 BREECH, AWEE, AM) FOOT PHESENTATfOyS. 

viflahle when the hea<l is <Ietaine(l hy n n-si>liiijr <« or cervix 
iit-eri, but preat mrv is iH'fvssni'V Ut avoid liicfnuion of cervix. 
In thc«e nisc-w \h. IJiiriifi* rfcuiiiiiieiHis Imrkward tnutiou by 
the feet and U|»on the nai>e of llie neck by ent-irtliug the 

Ptfl. 139. 




Tnetlun In After-comltig farad iintvted high up. 
latter with a 6ne napkin or silk handkerchief, aa shown in 

In any case where delivery of aftor-coniinj; head is delaytil. 
and wenkncHiia uf unibilictd pul.s<> witli spHsinodio coiilnu-tion 
of chibl's r«*|)iratnrv iiiiwli.* imlintte iiii|MinHng suHm-atiim. 
we may eiialtlc the cliibl to breathe l)L'fori.' birtli by paist^in;; in 
two finjiers between the face and vajrinal wall, thus niakinjjT 
a diannel for nir to tlie mouth or noytrila, or a larjje catheter 



TREATMENT OF BREICCH CASES. 



299 



may be paaBed intu the moiitli. In one cose lite was saved 
by trar.hrotttmtf before delivery. 

Ill all oiiHe:i of brew'h prt^ent4itiori every means uecessary 
for the riv^tonUioii oi' f<u.^|>e(idt;Mi aniiiuitiuu ia the iufaut should 
Ihj pmvideil beloreliaiid. 

In t*i\i*^A of ((HMj»M*// delay during crtr(v sUijres. arnnti/nniied 
with ttifuiptt/ftui uj exhaudion^ and due to a large Lreeeli. fiiuuU 

FlO. 140. 



Tarnler'i rorcepa applied to th« thlichs (DtxtviKli. tiTnt.) 

IH»!viH, or sonin other ahiiorinity, a tintrer, blnnt-li(H>k, or fillet 
may U^ j»!i.sswl over tlie jrroin and \\mh\ for triirlioii. 

If |»oH8il«h' to renrh a fo<it» it nuiy be jmlled down. For- 
oeitH and the VH*liM have U*en enijdoyed ; their une in iiuc^tion- 
able. They may be Iriwl, however. l»ef(»re end»ryo(oiny, whieh 
may, very rart'ly, be<N>me a Innt rt^ort in bad n\fiv» of iiii|)aetioD. 

()<vnsionnllv, owinjr to oblitjiiity of the nIeruH, the breerh, 
UM it were, ttiU on f/o* etltje of thr pfirir bn'nt, inHteml of pre- 
fleiitin^ over ilii eeatre. ProgresH i** imjicsBible, Trvutvwnt: 



;iOO BREKCn, KSEE, AND FOOT PnESENTATlONS. 

Relieve Uy nuinual jtreanure oxer nl)*ioincu, or put a huud in 
the vuj^iiiii and lil'l (ht; l)n'*'i'li <»H' ibe Hi4le inU> the miiUlle. of 
the Uriin. CviuUine Iwth uiuuiinilatious. 

Treatment when legs are exUndid, — 'l'hei*e are excepdoii'^ 
ca^eft, and otleu ow^wiuu tlifficulty and danger. BliouUl the 
dia|5iwwis have I.veeti made early, U-iiire the breech has de- 
scendeil W\n\\ brim of pel\'is, aud betbre the bag of waters 

FlO. 141. 




The fillet In donio-Bnterlor ptwUiuos (Lrsx.) 



has been iliiM^lmrjfe<l and the wonih contracted round the child, 
ccphnlie vrrttion, by rjierufii mnnipuhtf'inn, is best. Tliin early 
diapittfiis is diffioiili, and nsually not attemptoil wHtn enough. 
It oan i«*nr(fdy Im rpurluHJ <*x(V|>t by mappinj: <»nt tlie child 
by palpation over the nlidonien. Failinj^ to brinp ilown the 
head thtis early. Iiv ext/'rnal manipulation, the next expe*1ient 
IB t<> pass the hand iiiMde, all the n-a\j io fumUnt vlrru and 
bring down the feet — n niiKle of pmeewlinfr, at lHi»t, ditfieult, 
and endangering rupture of uterus, esixrially after waters 



TREATMENT OF BREECB CASES, 



301 



have hefu evacuuU**!. A iM'litT tiieilioti is lo |iui« in two fiu- 
gere unlil they reacli the |K>|j]iU'«l ti|mi't' of i\w iliigh ( preiVr- 
n[»ly the auterior thi^h), uiul then prertit the limit i^uhvarl and 
bnrkwartl, which at once flexes the lc*( aiui hriiij^ the f<x>t 
witliin reach, wbeu it cau Ihj caught and drawn down. (See 
Fig. 142.) 

rio.142. 





VcChod of brtnfflnit <1own tbc foot. (Prom Pabvin. after Farabibup and 
Varnimi.) 

NVhcn bretM'h hiii* dcscendcfl into {xdvic cavity, «>r !»ecorne 
iiujiacted. Version should l»e abandoned. The ex^>eiUeni# now 
at itur disposal, named in order of preference, are : fom^juty 
filttU hiiint-hinik\ rephntoirihe. F]x|K*rien('e luit* Hniply tlenion- 
Htratcil rtiat forccf** (miulo for the heiul) nmy U> also wifely 
appiie<l to (he briH'eh ^vhen il hae^ en^^u^ed in the {H'lvie cavity, 
and the U8 titeri is dilated. When ht[u have rotuleU (one to 



302 BREECH, KNEE, AND FOOT PRESENTATIONS. 

sucruiii 9LU(1 one tu pubeft) one bliute of forceps is appHe<l to 
sixcruiii ofthikl, the oilier to ;M)jrfc*Wn/-RHrfm'e of fhilil's tliifrba. 
Wlieii lii|)(> Lave nut rylat**il, but rernnin lrHUi!\'ertie, the bhidea 
aru jippliril to tlie fate ml surf are of xht thitfhg {see Fi^. 140, 
pH<;(! 2iH*), not owr the IriM'haiUerri, h» lIuU emb of itlades ifii- 
pinpe u|»on c'rwita *)f ilia. Traction only <iuring |)aiii8, .slowly 
aiul wiihoiit ^rcat torce, jissi>^le<l by prtiScjinT of haiulH of asisist- 
uiit over fuiului* iiieri tliruu;/ii alMlutiK-n. ShouM ff'rreje* fall, 
or breech l>et^M3 hiirh up to iniriiit of their application, hihI ver- 
sion Iw itnprarticable witliouL nt<iu^ danj.'eroUfi fon.-e, pa?^ JiUei 
over groin, in preference round the thigh diri'<*itMl anteriorly, 
and make traction (:»ee Fij^. Ki(5, page U\ib) until breech is low 
enoiijj;h fur ibrivpn, or for iiiigera to be hooked in groin : the 
wholy hand may ive passed into the vagina nial Im* made to 
graai[> breech ImhIiIv, it ihutid) in one gniiii and iingt^rs over 
op|M«ite lro( banter, Thf ftfunf-liool\ properly guardcil, may 
be of servicL', pa»*!***d <»ver groin for Iraciion. iStr Fig. 1413.) 
Its use re<piirfj* skill and caution to prevent injury U> i-hild us 
well a.** rnotlier In impaction cases wherr all these niethwis 
prove to be unavailing, JujmpltfjKeoiitmij ubonld be done if the 
child t»e alive. VVht-u child is dead, or other metisurea have 
failed, use cpphalvtrihe, applying il tiglitly to breech, and 
extract during jwuns by judicious traction. 

Treatment or Footi.in*; and Knee Cares. — The man- 
agement of the:^ c:i,«es is practically the same an in breech 
presentation. So i.** the niei.'hanism. Mo»<t castes nrtr breei'h 
pre.'*entations originally, the pre.«i»nting f<.H»t having lieeu rlis- 
placeil downwani toward the 09 uteri, either by the active 
motions of the child or by a gush of jitjuor amnii when the 
watert* bn»ke, or by some Hther proci^s. Karely lalK»r hryiiis 
with the heels pla^-ctl against the buttocks, the lower extremi- 
liert having the same relatitm to the bi)dy a.** is oliKTvrd in a 
kneeling f>osture. Footling cases are ofWn more teilious than 
when the breech presents; the firnall and irregular-shaped feet 
(or kuees) do not s<i well adapt themselves to the sba[H; of the 
08 uteri, hence dilatation oi' the latter is slow and laljor pain- 
ful. There is more danger lo the child during delivery of the 
ntterH-oming head, (br the feet, hips, and body come through 
the OS uteri withoui pr(Hlucing sutficient tlilatiition of the its to 
admit the head afterward. 



TREATMEyr OF FOOTLING ASD KKEE CASES. 303 

rro. iia. 




BlUDt-huuk tpplteil In breech prMenutluu ti'ARViN.) 



304 



TRAKSVERSE PnESEyTATIOy& 



Whether one or Iwth feet present, and whether at (he os 
uteri or at the os vu^nie, either hefore or after rupture of the 
nienibrane*, the hcff rule of trratmerif (in the alisence of auy 
e<mipli<'nlion) is In leave the ease alone— takinjr Hpe<'ia! care 
nnf to rupture the hag of waters — until the hijia are delivereil, 
svheu attive inter ft- reuoe may 1^ necessary, a.s tlesfTJhed iu 
the inanii^'inent of hreeeh caM.«, to prevent fatal ilelay with 
alVcr-<'(miiu>f head. (S<?e pp. 'i^M ami 2*15.) 

OcraHioually, unusual anil Herious ileluy may occur when 
the preseutiug parU are at the superior strait, owing to a foot 
or knee hein<r caught (tver the edge of the pelvic hrini, pre- 
venting tU'jscent. Tlie uhstrurtiug liuih shuuhl 1h» placed 
right, or luMtked down, with the finger. Since in iloing this 
there is a risk of rupturing the nienihraues (he they gtill UD- 
broken), try fre«juent chnnges in the woman's posture; this 
alone will sometimes remedy the difficulty. 

CompUx pifMctitatioiiM, uf a fool alongside of the head or 
face ; or of a foot and hand ; or of a foot ami a hand with 
the head or facv, etc., may require interference, ^^'hell the 
head or face presents, try to jjush lia<k the accotnimnyiug 
hand or fool. Failing iu this, the fool may l>e held duwu by 
a fillet^ while the head (or face) is jmshe^i up, and version 
|)erformed. converting the case into a jicivic preseutution. 
^>hould this be ini|KtssiHle. llie head (or face) may l>e ex- 
tracted by forceps, wfiilc the offending lind) rentains down. 
Should all fail, cnunotouiy may be necessary. 

When hand and foot present alone — i. t'., without the head 
or face — pull down the fix>l and push up the arm — really 
{Mxlalic version, i\b iu arm presentation. 



CHAPTER XVII. 

TRANSVERSE rRE8ENTATION8. 

Any presentation in which the child's bwly lies transversely 
ncrostt the |x»lvis, instead of rmUviAf-, is a "transversr prt'sen- 
tatiou :" hence presentations dIl the urtt), t-houKier, elbow> elde, 



TRANSVERSE PRESENTATIONS. 



305 



hack, ulvlonieo, etc., are all intludeil in this rliwsi. !>(>nie- 
times cuileil •* trunk " and "crow*'* prt*vuuiliuu8. They uccur 
uuoe iu about two liuudreil aud tlRy lubora. 



Fltt. 144. 



Fra. 14&. 





Lenirf|ilial(>-lliiic(or(li>nw>-autcr[or) Right CL'plialo'ltluo (ordono-iKMtcrlor) 
ptMltioti dF Wj/A/ nhouliler. iH«ltloii of r/j^A/ thoiiliJcr. 

For pnicticnl pur{>Oi«ee it w only iiecu«ary to study ttco 
trimsverso presiMitatitHiH. viz. : 

1. Bight lateral pretteotalioa (including right orui, shoulder, 
elbow, hand, etc.). 



Fig. I4A. 



Fu3. 147. 





Klftht co[*halri'IU«c (or •Inrio.antertor) I^eft ceiftmlo-lliiir (nr t1nr«<>-pi«lerlur) 
piiBlllnn of irjl ihouldar pualUnn of kjt ahoiilder. 

2. I^ft \iiif.n\ pr«M!Utatiou (including kll ftrin, elioulder, 
ettt.). 

Each of tlieae two yretentativnji has two " poojtious," yiz. 

20 



J3 



306 



THAKSVEnSE PRFSENTATIOyS. 



1. ni4fhl cephalo-iliac Uhe hea<], or "cephalic" eml of the 
child, restinif upon tlif rifjht ilium). 

2. Lift replmli>-ili«e (the "cephalic" entl of the chil*l reet^ 
iii<r \i[Hiu the /*// ilium j. 

Since, in the rujhi ceplmlo-iliac "|)ositiou '* vi' n rhjhi latcnil 
"prcsentiUion** (Fig. 145), ami iu the ^'/U:cjjlial(Hliac *' )xwi- 
liou" of a A;/Y lattTul " pn-sentutiuu " ( Fi^r^ 1-17), the hack 
(dttramn) of the child is liirerted t^jwanl tiie pmfenor wall of 
the i>elvift, these two puiitiifnn have also l>een <a]leil *■* thjtm- 
fntderlor*^ ouv:^', while the mlier Uvo jKisitiiMis, in wtiirh the 
domum of the chihi in directed lovvard the pul>e** { Figa, 144 
and 14H), are culled don^thdnUrior. 

Presentations of the uMomen and Lark are ven' rnre, and 
soon I>e<xinie cimiipe*!, ^^MutHnemiAhj, into lalertil pre^MUations, 
or they muAf. \h* so changed artificialiif. 

In cross presentationa the child is seldom or never exncily 
Imnrrrtfe^ but ohlitiueiy placed ; the h*'ad i» utfunlhj lower 
than the breech, a.** shown iu the figures, hence they are some- 
times cjilled *' obi'uju*'" iirt^^^ntalions. 

Mei^hanipm of Transverse pRESENTATioNa — ^There is 

MO mechaiiinm ; at least for pmcfirtif jmrpoKr^, it may he I'on- 
pidered that natural clelivery in crot^ presentations i:* mfclumi- 
mlhj impo.wbU; 

AcfiMittf, however (so wonderful are Nature's resources), 
there are tun* proce*«es l>y which, in rxcfpiioim! causes, delivery 
tmvt occur sjioutaueoufly ; but they are neither sutficienlly 
Wife nor fre<pient ti> be relie<i upon or waiteil for iu practice. 
These lire " a^iDntatieouii it r/rmn " and ** upoulaneowi cnylu- 

tiOH, 



SpoNTANEOui* Version. — That end of the foetal ovoid 
nean'st the jielvie brim (one end generally U eo, for (ho 
childV lM.Kly lies obliqHvhj acrntw the |)elvi», seldom exartfif 
inuiHverse), under the influence of uterine contraction, gets 
b)wer and h)wer. and the other end higher and higher, until, 
tiiially, the lower end rtlipc over the e<lge of the brim into the 
|)elvic cavity, and the pre**eiilaiioii luis then become longi- 
Imlinnl, either a hea<l or breech. Thi.i [iroeess us most ajrt 
to (K*cur ill muhipan>u.*J women, with feeble uterine (tintrac^ 
tiou. and bfjurr. rupture of the membraues; it i« sometimes 



SPOyTANEOUS VERSION. 307 

callnl ** jtp<}7itaneoua rrvtificiifiou," thnae wlio use tbi8 term re- 
serving the expression " njHmtuTirovH vertttort " for fnsea iu which 
that [uirt of llie t-hihl directed toward the CiuidiiH is turned 
dowuward to the jxilvie briui. This latter profeediug occurs 

KlO. 14H. 




Chiart'i troKU iectlou, rcprcMiiUng urratted sponUueoiiii evolatloa 

nioHl frefjUfiitly afirr rupliire of tht? niembrnries in worneu with 
fjowerful fM)ntrn(iioTif* (if ihe uterus. Iu thin ihe os uteri ta 
»t|»aHtn(Mlirnllv etMttrut-ted, 8u ihitt wltile no downward pro^'reas 
of that end of the fo'lnl ovuid nrnrest the brim can take pluco 
(it, on the rontniry, glidrs hiternlly and upward), that end of 



308 Tit A ys VEnSB presenta ttons. 

the child nmred Ifie /undtut ia forced all the way down to the 
pelWc brim, and a head or l)rCT'rh pres^'iitation results. 

While spouUUK'ijua reeliticalii^u mul vert*iou are uauiiHy 
aacrilwid lo utf rine r-imtnu-tiou, it is prolmUIu thai they are 
promotc-il hy aiiteru-latcrul prwaiure oi* tliu woman's thighs 
upon the alKlomen, wheu she assumes a sitting, kueelinj^, ur 
squatting jxMture. 

Spontaneous Evolution. — The child's body remains cross- 
wise to the pelvic hrini. Th» head n^tatea (above the brim) 

Fia. 149. 




SponlKiteoiu evolution. Pint stage. 

toward the nearest nootal)uluin, the breech toward the opposite 
sacro-iliac synchondrosis. The arm is extended from the 
ya;]fiua, the shoulder doflcendfl inlo the |telvic cavity, the neck 
rests behind the syraphysiH pubis. The ImmIv is then doulded 
laterally on itself, breech and hetid approarliinj; each other 
(just as one mitrht press toirether tlie two emls of a sausage), 
while the rounded, convex angle of duplicatinn is force*! down 
through the pelvic cavity to the inferior strait. The side of 
ihe child (the side of its chettt) isl>orn tin^t, followed hy hreeoh. 



A'i'OAIU JSJiO U^ H vol. VT102{. 



309 



and feet, whirh aro 8U(To«iivrIy for<*Hii down along the 
Snuii aud emerge at the |)enueun). Uuk*^ tliu [}elvi9 be 
lar*;e, the child «iiuillt aud uterine ooiitraolioii iilrcmj;, fuetal 
iniput'liuu i8 apt to occur, or the chiUI is burn dead tVoni the 
prolonged and violent compreswion to wliirh it haa l)«en sul>- 
jecled. See Fig. ]4H, |>age ^07, representing a case as exhib- 
ited by frozen section ot' cadaver (alter Barnes;. 

Fio. t»>. 




Spontanenui vTolatlnn. ftccoDd utitge. 

Wlien the prooe«f is succi'Sfifiil ita several stages are thoee 
shown in Figa. 149, l.jO. and 151. 

fVry nirf'hj a protvsw of Hpoutaneous evolution (different 
from that JuM de?icribe<I ) ivrun* in which the chihl is (felirrrrd 
with doubif'ti hfttitj — "r-i'olntio rotufupfirato nyrpnrf.** Instead 
of renmining above the brim, the hf-ud ettier/i the pflris vith 
thr /Wt/. into whirh it i^ deeply pre«<e(l, so that hrad and 
nbd'tnu'n oome together. flillnwiMi suecessively by breech atid 
legs. The second arm lies iK-tween the head aud breech. In 
the other more common mode of evolution, the hotly was 



'sio 



TRA yS rKRSE VRESESTA TIONS. 



Tif/double<l (luring iluUvery, body tvmiug firsl, head after- 
ward ; in the rare form, body and head reymtin douhUd and 
come U>pethor. This last ouly occurs with prfumiurc or 
mactrated iiifariU, or in abortion cases. Delivery is hastened 
by traction on the arm. 

Kw. 151. 




SpAnUncous CTOIutinn. Third itagt. 

Causes of Transversi: pRicftKNTATiox. — Premalurity of 
the lal>or. na<vnta prir-via. Nnrrownttw of pelvic brim. 
Great lateral obli(|nity of the uterus. Multiple pregnancies, 
t'ndne mol»i!ity of the child from exc<*sa of liquor numii. 
Accidental prw*<urc cxternnlly from blowH. falls, drets. etc. 
Re|>eated occurrence of cro8si-birth« in the same woman is 
pn>l>ahly due to a narrow ]x^lvi«' brim. 

DtAGvnsw OFTRAN8VKasi:CARi-:8. — Ry extoriml palpation 
and insiK-vtion the womb in fotnid to be uiif«yinmetricul in 
sha|>e. and longer transversely or oblitpiely than vertically. 
Hince in the hnje vuijurity \>i *«8ew the bnck of the child in in 
fmni (dorsivantcrior ]Mwition), iitid thf hmd Imrrr than the 
breoeh (at lw»pt early in lnlM>r or I>rtbre it beginji), one nmy 



DIAGNOSIS OF TRASSVKliSK CASES. 



311 



inwardly guess (often correctly) Ixtth presentation and posi- 
tion by iitftjiection alont: Palpalion in t!m\*iMuiierior [KMitioiiH 
reveals liiird, round, rc^iilur tumor of \win\ on one iliac t*tftfa, 
mid Hutt, irregular tiiiiior *A' lireec'h hi^li \i|i in i»p[>ositf (lank, 
partly ooucealed lieliiml falrfe rilis or hy the livur (8t^ Fig. 
]52j. iititiiijtiug plaue of hai*k tbllons cun'ed line between 

Fia. 1&2. 




DlagnotlM of abouMer prcwDtAtlon by palpation. {Afler Partih.) 

these two. Above the resisting plane, toward the breech, are 
felt the small parln in ehwtic space occupied by liquor amnii. 
The excavation iwunlly iMn|>ty, or small proje<i:ion of preseut- 
inp shoulder may l>e diw.H)vercil behind horizontal rami of 
puliea iK^innin^r to sink into brim. Tlie hea<l on the iliac 
fi»ssa may be made to ballot These arc the condUiarta observed 
eat'ly in Uibar or tttfoix it btfjins. 



XI 



312 



TH.iySVhUiSiC PBESENTATlOyS, 



Later iu labor, atlcr nicnihranea are ruptured and child's 
body becomes compresseil by cuntrnt-tiug uterus, the line of 
resintitig plane of back becomes more vertical ; the breerh U 
forceil uiure over to the median line, aud plaue of back 
appears to join head tumor almost at right angles. 

Ju dorso-;>ofl<crior jjoeitioua (extremely rare) ]>alpatinn 
reveals hard globe of head in one iliac f(»^a, aud large, tMjft, 
irregular breet'h hiph up on opjto^itc side, Uc^isling phiue 
of back (being behind) cannot be felt, or only with riiihculty ; 
while ohuitic s{^)ace of liquor amuii and small parts (being in 
fnujt) are ft ft eiufHj/. 

By vaginal examinaljon, early in labor, the presenting part 
and OS uteri are found high uj) and ditficult to reach. The 
bag of waters m elongateil in sbajie, sometimes jirojei'ting 
through the os like a glove-finger. The glolx? of the he^id is 
miasiug. Vaginal examinational should be made beixveen the 
pains to avoid rupture of membrauce. 

Diagnosis of Siiouldkr Prf5»entation. — By its rounded 
prominence ; the nbarp lK)r(ler of il-s acromion pro<*«s** ; the 
clavicle; the »pine of the ^cupula ; the liollow of the axilla; 
and eflf»e<.'ially by proxindty of ribn and iHUitoilal ffpacts, 

DiAONo**ia OF one BiiorLDER from the other when 
THE Hand and Arm are not Tangible. — 1st, OWrve 
the o{)ening of the axilla ; it always points ttjwanl the cbihrs 
feet If the feet l>e, tJierefore, toward the right side of tJie 
pelvis, the lutitl will lie toward the ffft side. 

2d. The tfcapula, iti* npinous procese e8|»ecially, will indicate 
whether the chiliTs back be toward the puhes or toward the 
Bacral prontontory. 

3d. A moment's reflection will show that a chihl lying 
across the |>elvis (let tlie reader imagine himHclf to be lyiug 
acrot« it), with its head in the ritfht iliiic f(»i«sn, aud its fMtcIc 
to the ptibi-fiy muM l)e presenting its ttft shoulder to the ]»tlvic 
brim — the " position " of the " prtwentalion " being, necee- 
garily, right cepluilo-iliac (dorsKvanterior). If the axillary 
0})eniiig hIiow the head to Iw in the left iliac l\nva, Jind tlie 
poeition of the scapula show the child's Iwck to Ite townnl the 
mother's flocrum. it will still be the left shoulder presenting, the 
po»Uion^ however, being left cephalo-iiiac (or dorso-posterior). 



TREATMENT. 



313 



The same data and deduction may be used for the right 
shoulder and its two "positions." 

Diagnosis op one Suoulder from the other when 
THE Arm is in the Vagina. — Gni^p tlie eliildV bund as in 
oniiuary hand-shakiIlt^ When the palm «ij* the haud of the 
practitioner and the pahn of the child's hand arc hrou)^ht flat 
against each other, if the thumbs of the iwo hands come togHher 
the hnnd of the child will he right or lefl according us the 
physician is using bis right or left 

Again, if the infantas band be at the vulva, and its palm 
be turned up toward the syiupbysis pubiH, the ihunih will 
point toward the right thigh if it be the right haud, and to 
the lell thigh if it be the lett 

D1AGNO6IB OF THE *' P(»SITION ** OF THE " PRESENTATION " 

BY THE Presenting Hand. — Extend the arm, and place the 
hand nujyine. The thumb will then always (xjint toward the 
bea<i» and the tacc of tlie palm will agree with the surface of 
the child's alxionien. 

Diagnosis of the Elbow. — By its three bony projections 
— the two condyles of tbe hunieriie and the olecranon ppxress 
of the uhm. The end of the elI)OW, like the axillary opening, 
ptiiuls toward tlie child's feet 

Prognosis of Transverse Cases. — Always seriouB. 
Oilen fatal to the <>bi4ti, Hjmetimes to the mother. Much 
dcpenihi uj)on the priwntation being corrected early, and ujwn 
the skill of the o^icrator. ^O -• . /^"^ - 

Treatment. — Early correction of the presentation — con- 
verting it into a bend, breer;h, or footling — by the operation 
of version or turning. Tbis may be done either by curtvntal 
manipulation ; intcmal manipulation ; or by a combiiie<] modi- 
fiaiti(»n of both methods, known nn bipofar version. 

(Note. — Version, and the several modes of j>erfonuing it, 
will be considered in Chapter XIX.) 



314 ISSTRVMESTAL DELIVERY, FORCEPS, ETC. 



CHAPTER XVIII 



INSTRUMENTAL DELIVERY, FORCEPS, ETC 



TiiHRK ure four )^rcat diviaions of operative miilwifery — 
four great methoilii l>y whieh delivery may \re accotiipliiilied 
wlipn the natural |K»\verH fail. These are: 

Firjit, Delivery by fort*e|)e. 

iitcond. Delivery l>y version. 

Third. By cultin^ oj>enition8 ujwn the mother. 

Fourth, By miitihitiivi; o|jeralions upf^n tlie cliild. 

Eiieh of these indiidtti a variety of diil'rrmit proredures, 
ami there are uuiuerous other utiuor riiiiiii|mlations i>ome of 
whieh have been already describe<J, and otiiirri remain to be 
conaidered). which are, of course, ulistetricnl operations iu 
every sense; but it ih when thesie minor methods are ineffi- 
cient that the ohfltetrician falls back U|>oii one or other of the 
fonr (^reiit niethodd of delivery jupt mentioned. Delivery by 
forcepjt and by rrmion are eA<entiaUy ohntrtriatl oiHTations; 
cutting oj)eratioiiH u|>ou the mother are dintinetly tturgicaLt 
and muiilaliug o[>ertUion» upon tlu- child are awkwanlly of a 
mixed chnnicter. 8(ime rc<'ent authors have included aU 
ojMrrations under the caption of " (ibvtdriv Surgvry.** 

It m ini|x)rtant to know that forv.fpH and vermon are far 
more fre<|uently required than tijc otlier two metho<lj«, and 
will ho resortHl to w^fuwionally by alfnoAt every medical prac- 
titioner ; while cullin;j; upi*nition»* Ujnm the mother, being so 
rare as warcely to allow the olwtetririiin to anpiire .nkill in 
Mieir |»erfornKiuce by ex[)erieiicci imght, in the interests of 
the patients, to l»e done by one already |iosse»*infr surgical 
skill, when such can be ohiained without injurious delay. 
I'uder op|)osite circum!stau<'cfi every olw*tctrician should know 
how to do these o|>Gration>», and not hesitate in undertaking 
their performance himsetC Mutilating 0|jerations ujjon the 
child are seldom require<l. at le:i«t in this country where 
pelvic defnrmilies (their chief fieM) are cumftaralively infre- 
quent. While they demand care, manual dexterity, and 
dp!il>erntii»n in their i>erformance, to avoid woumling the 
mother, they are done without heniorrhape {at least from the 



hXtRCKPS, VECns, BLUNT-HOOK, FILLET. 315 

living) nitil art* therefore exempt from that "fear of Mooil " 
whi<'h in apt U* uiiuerve and diKtiirii the M.*ll'-|Mj»ieK.sioLi of uue 
unatyimtonKi] to |>t>rtbnii i«tir^i<-al ofHTaliotiH. Iti t)ie interests 
of living fhihireu they are hein(r largely PupjihrnttHJ by im- 
prove<l metho<l:t in doing cutting operutioiit^ n]M»ii the mother. 

Forceps, Vectis, BLtrxr-HOOK, Fii.lkt. — A desen|)tioa 
of the forcejw may l>e fittingly prct'e^h'tl with a brief aet'^mnt 
of the other instrument.'' here name«L 'The Jiff rt w a noose itf 
cotton, t*ilk, or leallier tape, or an uncut skein <»f worstc*!, 
used for traction. The hwp having hern ])iu<fie<l around the 
part to which it ia to be ai>plied, the otl»er end of the fillet ia 
put through the nootte aiid drawn to form a nli[>-knot. The 
whalebcjne fillet conifists of a long itlip of this material, the 
endi* of which are Iw^iit toward eju*h other and joine<l in a 
solid huudle. A good fillet may l>e maile by j>a£eiug a strong 

Fio. lfi& 




Thct blunt-book. 

piece of tJij>e tlirougli a pieee of stout rubl>er tubing, the tapfl 
Wing »ewe<l to the tulte at each ciai. where it pmjeclH a Huffi- 
cienl length to a<lndt of u knot l>oing made to facilitate intro- 
duction, etc. The fillet is wldom uhhI exce|it for the occa- 
sional awii3tan<*e it may ren<ler in cert^iin arm and breech 
already mentioned. If the end *»f the fillet cannot l»e 
"pawed by the finger, use a large gum-elu*?tic catlieter with 
Btylet, bent tx) suit the case, with a piei« of lajx* fiLstcned to 
itfl extremity. When the catlu'ter is in position the fillet may 
be fixi*<l to the la|te and drawn through as de.sire*l. 

The bfuitt-lifniti- (Hce Fig. \ft-h \t* a cylindrical hhI of nteel, 
one end of Nvhich is nttacheil to a wocMlen hamlle^ and iho 
other bent U* form a fnMik. in the end of which i.^ an ^'vvf^" 
through which a fillet may be threaded. It is us(m1 uh a Hort 
of long artificitif finrftr for pii.Sf*ing the fillet anil making trne- 
tion ; it in but little eniploywl for the delivery of living chil- 
dren on acooinit erf injury it is apt to pnxluee ; but lieoom*^ 



316 INSTRUMENTAL DELIVERY, FORCEPS, ETC. 

of great service id the extraction of dead onea during em- 

hrvotomy operations. 

The vf'cdn ia ii tlattencd steel blade with a fenestra, Rhank, 
an*l huntile r«?eiiibliug a single Made of the strni»;ht furcejMS, 
and eurved to tit the contour uf the foetal cranium, (fciee 
Fig. 154.) It is seldom used, hut may be of t>ervice, aa a sort 



PlO. 154. 



Fio. IWw 




V«elli. 



ShOTi forceps (Dcnro&n'iK 



of artificial hand^ in promotin|r flexion, rotation, and exten- 
sion, when necec«ary in tlie nieehauiHni of lalwr. As a tractor 
it haa l>ecome olwolete since the inveutiou of foreejts. 

The /orwyM is a sort of pincers whose blades, like a pair of 
artificial fiand*, grasp the head and draw it through the j>elvic 
canal. 

The instrument ia composed of the Llwlt^ proper (which 



FORCEPS, VECTIS, BLUNT-IIOOK, FILLET. 317 

graap the heiiri), the lock (where the twu halves of the instru- 
nieut erues eweh oHu*r ami are "loc*ke*l" Uigetlier), thv shunk 
(place<l between tlie Icxk and hlndes to give length to the con- 
trivaDoe), and the handled (whieh are held hy tho o[jeratur). 



FUJ. 1,^. 



FlO. 157. 



e 



Long forceiM (HiKlge's). 



Blniiwon's long furcops. 



The two halves of the instruments are separately known a« 
the "right" and "left" hliide*, willed also **U]>|»er" and 
"lower," and "ninle" and "fynialc" blades, 

Foreepfl are either "short" or "long." The short forceps. 



318 INSTIiUMICSTAL DEUVKRY, FORCEPS, EW, 

called also " straight," have only one curve — the crania/ curve, 
which u<liipt« them to fit the cniniurn. Thcv Hre only used 
when the liwui ij* at the inferior strait or low down in lliv lavity 
of the |X!lvis. (iSn* Fi^. !/]">, |>ii^'t' 8 IB.) 

The fon(f forcepg, l)esi«le the "rnuiial " havealw) a '* |*lvic" 
or "i«icrnl" curve, hy which ihey coiitorni to the axi.s of the 
pelvic canal. (Figs, Ihij and I.>7, pajre 'Ml,) They nmy Ikj 
applied at almost any part of the |ielvifl. 

Action of Forceps. — They act chiefly as tracUrrit: slightly 
ati vomprejiMora ; warcely nt all u^ /crvrjt. They are aidi* U\ or 
sultstilutes for, iilvrine <imtraction. They occupy hut little 
8puce, owing to pr«tjc<'tioii of the [>anetal protulwranccs through 
the feuewlru! ot the hlades*, which always mrurs when the 
instrument i» applied in its most favoruhle |M-B*iiion, (lie long 
diameter of the head agreeing with the lung direction of the 
hlades. 



Cases is whkh Forceps are to be Used. — CJenenilly 
speaking, in all rai»ea where it is ne<'e*sary to haittcn <lelivery, 
provided their use for this purjHJPC can Ite wifely and suo- 
ceeefiilly employe*!. The circumKlancot* under which their 
application is to he preferred to other nio<h^ of operating, and 
the caK* to which they an» i*iK'cially adnptc(i. are »> varied 
and uumerons that tliey need not l>e re('ite<l here ; they are 
considered elttewhere in connection with the dilfertrnt kinds of 
lahor and their coiuplicutiou& 

The "Hian" and "Ix>w Operation." — When the head 
(or face) of the child is at the inferior strait, or htw dowii in 
the pelvis, it <^)iistitutcs the '*Iow o|>eration," and is compara- 
tively ea>y. Wljen the head is at or ahove the sufierior stndt, 
or occupying the higher planes of the j»clvic cavity, it Ifi the 
"high operation." Thih distinction is imjMjrtaul, Difficulty 
and dangers of lorcejie o|»erations iucrcatie, aitrrijt ponhus^ 
from Ik'Iow upwanl. 

Conditions 1']ksi:ntial to Safetv in Dki.ivkrv kv For- 
ceps. — The Of* uteri nnint l»e tlihite*! ; the menihranes* rupture*! ; 
the reettun and liladder empty; tlie [H'lvis of suffieient size 
to admit the child ; and the o^pcrator niu^it |KWHei<u a rei^uisito 




APPLICATION AT THE INFERIOR STRAIT. 319 

amount of knowledge, stn-iipth, sintl nuiiiipulntive <lexterity. 
FoivtrjiH, however, iimy Vk* applicil hcfort- the iw uteri is eora- 
|iletely clilated (it' it be palulnuh (in*l (liiululde), uud hel'ore 
the heiul \\i\s passed tUroui;h it, pruviileil lUt- diuiiLCfrsi uC delay 
are amiiiferJtly j^ri'iitcr llian (lie ri^ks iiicurrLHl by iatrodudog 
the htades of the iiu^ilruuieut into the uteriiH. 



AxTiHEPTir pRKfARATiON. — Make the alKlonien, thiplis, 
and vulva ase])tinilly clean by scmhUin^' with winp antl water 
ami npplyinjj; a 1 : 2<M)0 biehloride Kilutimi. ('leunse the 
vagina thoroughly with a hot "1 per rent, ereidiu solution. 
The haudfl of the o|>erator are prejMire*! awptieally vi» iif^uul. 
(See "Jjibor," jiape 'J14.) The fun'ei»& are rendere<l sterile 
by boiling and |)liufd in u h |kt cent. earlH)!!!' aeid wdution — 
preferably iu n deep pitrher — ready for use. Before iutro- 
ducing each bUidf, lubricate it with cflrbulizeil vaf>eline or 
molliu, 5 j>er eeul. Aseptic net*<lk« arnl HUlurr*^ will have been 
j^reviously pre|»ared tor the jx^rineuni xi^ a nuiKer of course. 

Mode of Appmcation at the Inferior Strait when 

THE O'CIPl'T HAS R<»TATKT> T<\ THK PlMK' SVMfHYHlS. 

Tiiii* is the niniplei^l and inoft eatty of all for<*e|iM o|H'niliou8. 
Place the woman on her back. AmcHthe!*ia may or may not 
be necessary, aceording a? the \v\\\\ and ditticultifj* to be anliei- 
pated are, re»|K'ctively, great or little. Aft-i.^'tanti, at leaHtone 
even in the 8ini[»lej<t cji^es, will be retjuire*!, but an intelligent 
nurs*' will olien be hulKeient, When anastlieHin is niseii. addi- 
tional ttsp^istants become nei^'c-Ksar}' : one t<t give ether and two 
otherw (one on each t^ide) to t^upport the lower lindiH. The 
"left" ("male," ••lower") blade is intnxluced first Which 
of the two bladen thi» m nmy bo n.^vrtained as folhiws : Before 
they are takfii apart look at the Im-k of the iurtlrunient, while 
it is hebi with the convex border of the ij>acn»l curve dcwnward 
and the handles toward you, and aB(*ertain which Khauk is 
uppernuwt: it is the oue wbose handle is toward your right 
hand (the "up|)er," "fcnuile," "right" blade). Lay it awde: 
tbetdber blade, held iu the left band, must be introiluce<l firsL 
(Irasp it just above the lock, much in the same luanner «» you 
would a {>eu, t^i (hat the handle rests between tlie thuud> and 
the iniiex-tinger, and U|H>n their junction. One or two fingers 
of the right haml are uow first iutrotlueed lietween the child's 



APPUCATIOS AT THE INFERIOR STRAIT. 321 

niuvcniput of tlio Uhvh, rcK-kiu^^ il first up t^wnnl the jmbwi, 
then dowu toward the <:occvs, nmv farililau- its entrance whea 



Fio. t6». 




Ititruductlunur wcnnd bladt. 

till' hi/.i- hI" thr ln.iiil iimkeH il a lijk'hl tit. TLe fingers insifie, 
linvin^' nfif-ortxiint-il that thv lilii<ie is entering pn)|ieHy, nre 



322 ISSTRUMIu\TAL DEUVERY, FORCEPS, ETC, 

^railimllv vvitlulnuvii ; tiixl when t[iL- riitl of the instrument 
hius nliout j>jLsscU ilie f^juator of the hvud the U'i\ hand is 
pluce<i uIhivo iiiiil iirariT ill*- end of thn hiinille, whieh is now 
deitri-ssed lo^vjird Ihe ]>eriiu'iini, >vheri' it in lifUl sK;idv hy an 
tkiHiHUiut, while ihe oiticr htade, held iu the ri^dit hand and 



Fio. 160. 




ii>v; hHiit)lt_'i!i )•< l< 



\lriip>liiii. 



preceded l»y two fiiijrere of the left, is iutrodured along 
rijfht lateral wall of th*- vaifiua on the other ftide of the head, 
in an exartly similar manner at* the tirst. (.See Fij;. 159.) 
When |in>|HTlv a|i[ilie<l, liie iieeond Made eronsMt* the tirHt one 
near the lock. The ueJtt step ii» to Iwk them. 

The ojierator, taking a. handle in eaeh hand, hy slight ad- 



APPLICATION AT THE INFICniOR STIiMT. 323 
Fia. 16t. 




IntroOucllon nf lowi^r blade of foreepf. 
Fio. 162. 




Irtinxliii-tliiii uf tJ|»[M.*r Idiulu, 



324 I^STRU^n':sTAL delivery, forceps, etc, 

justiug movemeutfi p^els both blaiies on a pro|ier level, the lock 
ti|i[i« into iMwilinn, and the instrncni'Ut is remly for tractiuo. 
lu tonvfitt, like H*xlge'a, having a wrew lock, the screw must 
be tighleuc'd bt^fore peribrming tractiuu. In applying the 
forcejis, priXHt'd only between the pnins; iu using (ravtiony 
ouly duriufj the piiiuR In the ab>>en(f of pain?, imitate them 
by intermittent tractions and intervals of reet ; each (^ODtiDU- 
0U8 pull Dot to t>e hmger limn one minute. Iu tJrawiog out 

Tig. 1113. 



^ 



\. 



^ 



^^ 



Furcoin In position. Tmrtlon fn Kila of brim, downward Kud baokwifcrtf. 

the head by traction, avoi<1 harte and violent pulliug fuulesB 
imperatively nfpiirod ) ; tlraw by the strength of the hands 
and arni«, not by banging the weight of the body tni the ia- 
strunient ; <iinrt trnrtittn iu a line with the axis of the pelvis. 
While ouf hand gras^ic the liandlesit let the other gra^p the 
lock, and rest the tip <tf its index-finger iigiitnst the iH.*dput to 
guard against the head clipping out of the bbidi^ ; in renting 
from trartion-efforts betwetMi the pains, see thitt the handler 
art' not liebl lightly togrther, »> as lo make ctmtinjww cum- 



AftUVATlON AT THE iSlKHlOR STIUIT. 325 



prt-eKioti, by tlu^ lilades !i]wni llu- luud. Krcp llu* Immlleii 
douii. i^y tliut triirtion is iiKule uliout in u hori/xiutai lint*, 
until the ocripilnl iMul i»t" the m-ci|iito-uK-iitii] diiuiHiiT is 
lieginiiing to ts*<'Ji|H; under llie |puKi(' arrh, tlitni gniduallv litt 
tlteiD up, in a line ^vlth tiie axin of the outlet, t4)WHni the 
rnoua veneriis in ordtr that "esteupioii" ot* the occiput up 
iu front of the pubic syni[»h_vfii» may take place. (Fig. 160, 




last ilAge of cxtnrtion. The hftmlteH t>elng^ (CTAtlunIly tnmect nptctwan) the 
mother's ubdowpn, to deliver by " vxteivtun." 

pngo 3*J2.j Inex|>cnence<l oyporalors vMiof/if continue trm*tion 
too louK before ln^jrinnin^r exlerifion. When (K-riput is well 
Ijelow puhic arch and Itack of cidld':* nork ht'himl pidu's pull- 
in;r doee uo ^w«i ; extension, hy lifting; liaudles toward puhcs, 
nuirtt now hejriu. Walcli the i^rineuni and j^uard it irom 
rupture an iho Itiparictal ripmlor cUKTjrit*. KcJidjubl the iu- 
struuieut from lime to time without withdrawiog it, if ceces- 



326 I^STRVMESTAL DEUVERY, FOItCEPS, ETC 

wiry, 1<* ktvp the \tm\r. «lire^tion of llie lilade? purnllel with 
the hnijLT 'lianifUT uf the head ( es|M.M'ially duriiiff " exteiisiou " ), 
otherwise the Itniiiiiul extrt'tnilits^ of* tho l)lntl(« will project 
ftiul injure the |)eriiieuiu or vajrina. To avoi^l this rij^k more 
w>m|)letely, some optTaiors Hike otf the instrument, just before 
the heat! einerL'er*. ami linish delivery, if further artiticial aid 
be neee-s^ary, by luatiipiilation — a tinger introduced into the 
rertuin drawirijr <mi the chin. 

Wliile thus far we have referred to the ajiplinitiou of fori'eps 
with tlie woman lyin^f u|i*>ii her hack — the usual jMisition in the 
United t^talefi — the methi>«l ot' usinj? the inf^trument with the 
woman in the English iR)!*ition, ujxin her left side, may lie at 
oueti undei>loi>d IVnni the preeediug ilUwtrations taken from the 
work of I'rof. IMaylair, of Ixjuduu. (See Figs. 101-164.) 

Ohciij.atouy ou " PKNmi.uM MovKMENT." — During 
traetion it in tmi neeesaani' (as was formerly sup|H»se<i) to sway 
(he liandley t-o and fro, laterally, with a view of K-verin^ the head 
out of the |»elvls ilh a enr[K»nler "roek.s" a nail in wiihdraw- 
m^ it from a hoard. Siure there is no niehet like roughneffl 
either to the [»elvie canal, foreejj**, or head, nothinjr can be 
)j^UDe<l by thirt movement, while the sweep it tioct-s^irily ^ves 
to the entU of the bU\des may injure the soft partj*. In certain 
cases where the hejid is fixed and Hrndy im|mcte*i in the 
pelvis, such a motion may lie justiliahle to disloilge or looueu 
It, but aft<'r tliis the lateral movenn'nt is u.'*ele**. 

Authorities differ on this matter; some continue to prartise 
the |)endnlum tnovenient, anti explain the theory of its action 
satisfactorily to themselves; others do not. 

8ince the pinch is most otleu in the anU^ro-jMttiefrior diameter 
of the pelvis, the Interal movements would seetn merely t4> 
swing the head from side to side round a oMitral pivot run- 
ning from aacruni to pubes. Theoreticnlly the ti>and-fro 
luovemenU would ap|H'jir to be calhHl for in the ntltrr tihrftian 
— antero-iK^jitoriorly, in order to levur tlie head down through 
the two ends of the olwtructin^ conjugate. 

Appi.icationb of F(>rcki*b at IxFKRtoR Strait whkn 

THE OfM'irUT HAS RoTATEU T(» THE SArRl'M. — ForCCpe 

shouhl not U- applied at all in these ciuser*. until a reasonable 
time has been allowetl and every pro|>er eJfort made (see page 



I 



I 

I 



APPLICATION OF FORCEPS AT ISFKRfOR STRAIT. 327 

266) to i>romot^ nriterior rctaiioii. uiileii«» iiKlc-etl, ai'cMeutut 
circiimstaiH-eK reiidt-r «lelay (luiitreruUM. Then, howover, the 
u[>enitioii is MM tiillows : Tiie Itlailcs nre |>iit in pxartly hh de- 
srrilied lor ciiac-s whore the wripvU huj* rotated anteriorly. 
Butsiiice the occiput is now tiiwnrd the Hnfrurn, the ejinmoii 
wilt, of couFAe, he downwaM utiti fMirkntird orer thf pfriiieuiu^ 
innti'ttd of u|m'nrd toward the pnlies; henre the hnndles of'the 
in^trunieiU. at liml lifted n^uniewhat upwiird tuuiird tln^ jmhc** 
to dniw the (wvijiut up to the e<lge of the perincuni, nuiHl, 
when the heiid enier^eH, he ilirwled dotrnwitrd and httvhttfmf^ 
inisteact of townni the mfmi* venetli'. A moments reHe^-tion 
will show that the Khort MmitjUt forroftn {without riny wirn// 
cunt) should he use*! in these cases* ; for the said curve \» oidy 
odapte-d to follow the axis of the pelvic i»anal, hut duriiij^j 
backward extennioii of the occiput over the perineum the head 
departs trom the axiiil line and goe^ iu an ul!ml!^t o[t)xj8ite 
dirtH'tion. If the cttnrti (orirt'itH were used, the enit.s of the 
hhiile-s would impinge agaiuM the puhic nr<'li while the handUtd 
were being *lepre»wed in tolltiwing the movement of hackwnni 
extennion. Again, owing to the (h.*|ilh of tlie [Kisterior |)elvic 
wall l>eing three times as great a« that of the anterior one, 
there i.s so much the more <lilliculty in getting the occipital 
emi of the occipito-mental diameter to escape over the edge 
of the iieriiieurn. hence greater danger of hiceralion, and neces*- 
fity for extni t^are that the occipital [»oIe rtfiihj shall have 
cleared the ]>erlneum i>efore exleiinion in attt^nipte*!. 

In the eases of ocA'ipito-|M)sterior rotation, in which the 
forehead, face, and chin 8Ucr<*sHively escaiH* iimler the pulK« 
(which wjniPtimcs goes on while the furceps are heing used), 
the caw heniining a fare prejteutatiou at the lust uiomeut 
(see *' Me4dmni.-Jn) of K. (>. \\ I'ofiition," page l!6li), the handles 
are elevated toward the jnihes, f(»r, the chin having emerge*!, 
the mechanism is c<iniplele*l hy xtn ftcrion ujj toward the mon^ 

Appli<:ation op Fokcki*b at iNFKKtoH Strait whex 

THE 0(< IPITT IB TOWARU ONK OF THE ACETABVLA. — Here 

itti rotation has owurreil. The huig diameter of the head 
(K'cujiiee the tsame ohlitjue diameter by which it tinterc<i the 
8U|»erior stnut. 

Ab a general rule, apply the blades just a>t if rotoitioa hwl 




[28 rSSTRfLVKSTAL DEUVKRY, FOHCh'PS, ETC. 

of^'urre^l, for. duritiir llu* siilj.st'qiient trfiftifin, roiutioii will tale 
place itutide iht iHdrumciiL Tije ItlaUtJei routuriu U> the «i</r?t 
ttf ike pi'lrUf luit ^nup the lurid oWnjuehj, one over th*'; xide of 
the foreheail. iht* ulhtT nver the side of the iwTipul. They do 
Dot »o uearly rt|i}>rout'h each (»ther, heiu'e the handles are wider 
aparU and th<* fbrtvfia are more apt to nlip during trucliou — - 
on ac^'iilent to be avoided hy addtiioaal care. 




Forceps tpj>llcH] ut Inferior atrnlt : occlpat Ut It;^ areitiltutum. 

Another mode of nixTatinjr is to pln<'e the Idades over the 
*i/ff« of the unrotate*! hfnd, hih' hhidr iH'itijr passed iu alunji; 
the Kuroiliac fivnchondrohis the other near the op|K»site 
m.-eluhulum. When the iiislniineiit is thii?* adjiwtefl, the 
haudJej* will he diretletl deeideiily toward that iU'i^U trtrrv- 
sjxindijijf with the iitftalxilnm at wliich the oc4-ipiii is plwed. 
(Hets Fi|^. 1U5.; iJefure or during the tiret traction-etfortfi the 



APVUCATIOS OF FOHVEFS, 



321) 



0(^'i[nii irt mmie to roUilu to llic ptiUfs \\y ^'eutly ilirwtinfi: the 
ImnJl^'ri to (he nie<liiiii liiu* of (ho intiT-R'Uiorul sfiare. This 
mode of 1))KTUtiIl^^ while iiinre MMCiitilir and lU^-inihlo thuu 
tlie other, retjuire^, in nn«*t fuj*eii, ;i ti|ifn:il .skill, mwX from il^ 
(liflicuk fxe<-iui(>n b not resorte<l to ait oiWn oh th« simpler 
methixl lirst alwve given. 

In (ioiug the opt-nuiim the thifjihs must l»e ibroiUly Hexed 
to f^et them out of tlie wiiy of the haiidley of the instrniDeiit. 

When the (Kviput ir* to trff uretMhuliini a|i[ily trnvt-r hkule 
fird nloiiiT left suenHiliut; Bvuehomlrtteit* ; then ijec-oml blade 
iwhiiul n;<ht melaljuluin. 

When oiviput is Ui ri^^ht aeelahulum it in Wvt U> ii|*ply the 
n)tprr hhnle Hi>t. iilonjr rijfht hiicro-iliac yynrhondrot^is, and 
holding; ij.-i hinnlle up 3*n<l on one sifU\ out of tlie way, put iu 
tie'.-uuil hiaile unUeriitutth it, t>ehintl left acetahulum. 



Arri-R'ATioN OF FoRCEW AT Infkkior Strait when 

THE (HlMIHiT IS TOWARP ONK OK TIIK SaCRO-ILI Af SyK- 
CHONDRusRs. — This Ih Still more iliffictill limn in unnttated 
anterior |Kwition8, hut the two modes (tf <)|K'r;iiLin^^ jukL men- 
tioned for them may liere Ire en»ployf<l ri>referaldy the first 
onet, notin^^ the diiferemv (when the seeond method i.s at- 
tem]>te«i) in the tiirnrtiou td" roUitioii. viz., bnekwurtl to the 
flaerum, instead of forward to the pul>es. As Ijefore staled, 
every eifort should have heeu previuasly made to n»(ute the 
oeciput to the piihfx : failing in this, there is nothing left hut 
to n>tate it to the wicrum, nnd deliver it in aciHinl with 
naecbauidm of oecipito-[KMterlor |xj6itioiiti. 

Application of Forckps wiikn tiik Head is in the 
Pelvic Cavity bltwkkn tiik two Straits. — (leneral 
methtnlM the same as already (h'-^erihed. The in.slrumenl re- 
quires to he ptLssetl further up ( henre long, curved foreefw are 
UHieswiry). and the traetioii muni Iw made more in a l»aek- 
wnrd direction, in <>»nforniily with axe;* of higher planes of 
|H'Ivie canal, hy directinj;; the handles more deiidedly down- 
ward toward the perineum while ])ulliug efforts are heiiig 
made. 

In these ejustv, as in all others where the head nmy ruit have 
i»»eii entirely through the ttts uteri, tlie fingers* that precede 
the iutroduetiou of the hImJes should feci that the ends of 



7WJ? HWH opEu.vnoy. 



331 



titruit-, version iH ii.«imlly |>r**iV'ral»U'. Tin* ionTpn is iiilrtMluced 
ill llio iiduul niauiK^r, l>ui. uf (tnirbc, liifjlier up, ho thai eveu 
the l(K'k may enter the vulvii. The hhulfr* follow liie sides 
vj the pvlvin^ no matli-r what '* |>0}*ilio[i " tlie lii*a<l may oc- 
rupy, hfiMf ihry jrrasp iJie l:ilt<T frhliijtiely. aiitl thtre is 
great liai)ility to slipping of the iiiHtruiiieiil, iiiul danger of 
the tips of the bliule^ iujuriiig ihe interior iif the uterus. 
Truetioii must he made very slowly at first, uud deeidrdiy 

PlO. 167. 




i^ltnpAnirsAxiB traction U>tcep». 

bitrku'iird nn*l downward in line with the nx»V of the ptane of 
ifir Hiijtrrlnr filrnif, hy keepinjtT the hanille*' a» near the etK'eyx 
an {Hissihle. !'■• fitrilitnu- (iiis hackward trartioii. Taniier hna 
eoustructed » spi-eial iiiHtninient ( Ki/r. 160, pn^re IVM)) with 
curve«l luuullrN, jH-rforjUi'd hy a st-rew to hold the hlatles in 
euntiu't with Llie rldhl'n head; these hnudlcH titcacty the in- 
struriient uiu) iiidit-aU' tlie ditvctlott of traelioii ; thr/orrf of 
traelion is applit'i] to the htwer handle, or erof;s-har, attaehcd 
to the traetion hmU fastened tu the hlade at b (Fig. 167). The 



k 



332 LSSTkVMESTAL bEUVKIiV, FORCEPS, ETC 
direc'tiou in wliieh axi»-trnrtioii fwi Iks thus employed is well 



Kiu. ica. 




WilL'ber'i pusltlun. 
FlO. 169. 




Plagmm to show Increnec In cnnjucnt« In Watcher's position The dotted 
linos show pnltes ami LVtnJitfmtv with the li'^ linn|flnK*J<'wn. Tht* i>Iuiii Kn*** 
Mhow the »amt; whtni tin* U'gH arfiiippiirUvl. KulatluniKcun about ihe |k>IuI X. 



TUE HIGH OPERATION, 



333 



illustraleil by the di^tle*! line m Fig. 167, showing Sinipaoii*i 
mwlification of Taruier'n iiiHtnituent. An hour may he re- 
quired to bring the head down to the |>elvic floor, and care 
must \ye taken to diro<t it in ncrordanre wiili ihc natural 
DKicliauiitin of lal>or as far as practiruhle ; and al^o that the 
traction cont^ist of alteruute pulls and pauses, in imitation of 
aaturul labor pains. 

Fio. 170. 




lIcFcrrAn'i Ibreepi. 



Rerently Walcker's position (see Fig. 168) haa been used in 
these dithcult cases to increase the conjugate diamclrr of the 
su|)erior strait. The woman is placeil on lier back with her 
bips not simply nt, but pnyrcting owr the wlgc of the IkmU 
her legs to hang down toward (lie tlimr without any 8Up|)ort 



THK mo 17 OPERATION. 



335 



For securiug axis-lrucliou various motlificntians of the 
forcepe have l>een C4>]itrive<i, notably that of Dr. McFerran of 
Philadelphia (Fig. 170), iitul iJreuss axitHtruction iuerrumeut 
(Fig. 171). 



Fio 172 




BtflpbttnaoQ 8 rootbod of axis- tncl Inn. 



Prof. Stephenson, of Al)erdeen, us«s a steel rod booked ia 
fVoot of the lo<*k, a* shown in Fi|;f. 172. 

A still l>etter device is the tmrtion hmLs of Dr. Keynohlfl 
— two separate steel hkJs hfwked into the fenestrre of the 
blades at^er their inlniiluoLion. th<; other ends being curved 



.33(5 INSTRUMENTAL DELIVERY, FORCEPS, ETC. 

round the periueum and ik^tened to n solid transverBe handle 
for nxiMi'»(*tion. 

The meilKxlft of making tmctiun with ordinary forcepc aod 
with axii^traclion instrumenU are well seen in Figs. 17^^, 174, 
17<j, pages ^;i*i. 'XM, and 33(?. 

If thu heml lie altogether above the superior etrait, and 
movable — ». <*., not yet fixed in ita jxtfitioti by auy partial 
engagement at the brim — version shuuld certainly be preferred 
to forceps. 

FHi. 173. 




Trartlun with .^linp«<m'i fi>ree|Mi. 



Dasoers of Forceps Operation. — I^ceralion and Hruift- 
ing of the utcru^ vagina, and perineum ; the vaginal injuries 
»omelinie:t involving rei'tum, blndder. and urt^tlini. thus lead- 
ing ti> Hulweqiienl nU-rraUon and Hstnbi' : niptnrf "r injury to 
veiuH iind PuItHtjUfni phlpbiiih: (xtHHihly fnu'ture of )H.*lvio 
Imhi«>9 and ik>[Hiratiou of jtelvic joiuls when great fon.'e is eio- 



VASGERS OF FORCEPS OPKHATlOy. 337 

ployed. Dan^^erp to X\w r\\M nre : abrnsiun, (»outu.«lon, and 
lacerntion of the t;kin ; lU-pre^siuu or fVmrture uf t'niuiul bonis; 
larerution of l*I«>«Hlvf¥si'ls. uiid ron.s(*qiiettl :^ulKMitjiiiKous hema- 
loi^ie; teuiiHirary tacial pal:*}' from injury to lucial nerves. 
Th<^ugh no lusiou may l>e apparent externally, the chiJda 

KliJ. 174. 




Tnetlon with Hsls-travliuu lurcujie, 

lirain may have Seen injured, and idiocy or other form of 
mental ditfeaw* renvjll in consetjuenee. 

Tiie //royj*<w»*.i in forcejjs cases largely dejiends npon the 
condilioDD preccdin;? and requiring; their application, and 
upon the care um) ttkill of the o[>erator. It is, of eourse, more 
favorahle. other things e<jual, in proportion as the bead is low 
iu the [Hflvitf. 
33 



338 issrnuMEyTAL delivery, forcevs, etc. 

Forceps ix Factc pRESEjn'ATroNs. — When the face is at 
the inferior atrnil nii<l tlie rliin has mtateti to the pultes the 
operutioD is ens^y aui) almo.'^t itU'iilicMil willi that il(.'ti<^ril)ed tor 
hmui ciwes with tlie ui'i'i|ii]t to puliic svmph\>i>t. The bimles 
are applied ou vnch nhiv, aud, atler irac-iion ham hrnu^ht the 
tip of the chin well oul uiidt^r the puhic unh, the hamiles nre 
directed up over the muua veneris, to pniniote delivery by 
tlexioQ. Care must he tukeu to jja^ the hlad»j J'ar back bo 

Fiu. m. 






■h 



AxU-tnctluu with onUoary forcers. Head ataupcrloraurftSt. 



that their temiinal ends fit round the occipitul eud of the 
head, instewl of digtjhi^ into it, when the hnndles are oom- 
presee^]. (See Fig. 170. pajre 33il) 

When the chin is toward one of the afetnbula at the lower 
strait ilie same rules may he applie<i its for correspirtulin^ uu- 
robiteil anterior ixwitions of the ixripnt. In fiwe <iises, how- 
Gver^ the chin is apt to he somewhat U-hind the acetabulum, 



DAyGERS OF FORCEPS OPERATION. 



339 



nearer the centre of the ilium, tlie fuc-e and head more direotly 
Iransverse in the pelvis, tlmu LXTun* iu vertex prcskjiitntiou. 
In these the hhules cannot well Iw applie<l to the aides of the 
peirU, hut should he prussed, oue idoug the siw-nvilinc junction 
and the other near the op|to8ite acetiihuluni, bo as lo grasp the 
gidejs of the htad, and rotation vinst occur, either spoutane^ 
ously or by the aid imi>arteii hy the blades, before traction can 
do any good, 

rn. 176. 




Forceps In ftice prcfcnUtlon Ht outlet. 



When the chin has rotated to the mcrunu delivery hy 
fjrcejM ia meohanienlly ini|>oftHibIe (see "Mechaiiinm of Face 
Cases,*' pnpe 27.'i i if tlie fiptus aud pelvia are of normal siz-e. 
Wlien llie ^x\rv ih iit the ifiijtrriur Mrati, or hij^h up in the pelvic 
aivity, and ('irrunislanres rffuire tieVivery to be fmstenedj ver- 
sion must he preferred lo forceps. And when version rannot 
l»e acconipiinhetl. the ouly remaining resorts are craniotomy 
wad Ca»arean section. 



340 rySTRVMEXTAL DEUVEBY, FOItCEPS, ETC 

Forceps TO THE A FTERcoMiNG Hkadin Bbee(H Cabbb. 

— When the several nianipiilaiioiu* nlreft*ly described («ee 
pages 2y4-2t*Mi for deliverv in these t-a^ei' tail, foroe|ttt may be 
trieti. 

In the more common cases in which occiput has rotated to 
puhttj and fWreheud to au-runi. the \hmI\ of the child \» lifted 
up ti»ward the nioim vcnerii*, and the blades n re npi>lied one 
on each aide of the head, as l>efore described, the handles 

Fio. 177. 




Forceps applied to aftercomin? head when occiput ha« r>-<ti)l*.'<i (u pubet. 



I»einir first ck*pr«wil toward (he |H.*riiieum. es|>ecially when the 
head is hi^'h up, hut nuule to i'oljow the l»tdy toward the moua 
veneria, as thi* chin, face, and forehead successively emerge 
over the cwcyx. (See Fijr. 17V.) 

When the rK'ciput has n»tatcd to the sacrum, the direction in 

Lwliirh the childV Imdy ih held during the ufe of the instruinent 
will de|»eTtd ii|Ktn whether the chin in caught ahoiY or <tij)piug 
beiQtP the puhic arch. In the fomur (and rarer) case-, the 
body 18 lifted toward the puhes, while the forceps are 



VERSION OR TUnyiNG, 



341 



in to the occiput, whieli w ilrawn out fn-ttf along the saorum to 
the |^»eriiieum ( ** L*oiaiuue*il fxtt'iisiun '* ), tho hundles buing 
lifted toward the ohild'if back as the hemi \s boru. (See Fig. 
134, puge28i».j 

In th» latter case ("continued flexion") when the chiu \s 
below till* piibcs, the hoi!y iiuist 1k^ dc|iii«scd Utward the jx^ri- 
neum, while the Idade^, having: l>eeri applied t<f the .siiles of the 
head, the Kaiulles (at* ihc ehiii, fuee, and foivhead nun*- out 
under tlie pu Me arch) aire deprw^ned tuwarti the ehiM's abd)>- 
raen. (See Fi^. 13H. pujre 2?4M. ) 

The applieutiou i>f tbrcejis when the ufter-eondnp hejid is 
urreated at the nitperior MraiK is u dittieidt t)|>eration, and 
mannul pressure iVoni almve, (H>iijoiried with every other 
means, stjited under the "Treatment of Breech Cases" [ptige 
297), should be faithfully triwl before attempting their intro- 
duction. Their une, ImwevHr. in U^ tjike preeedenee of erani- 
otoiny in any ca^e where this is likely to l>eeome necrt^sary, 
esi>ecially if the child Ui si\\\ alive. 



chaptp:r XIX. 



VEB810N OR TURNING. 



Version is an operation hy which wonie part of the child 
other than that origiually presenting is brought to the su|>erior 
strait When the ht^d is brought down, it la "cephalic" 
version; when the /^-f/, "|M)dnlio." 

When ft face or brow presentation is chanfje<l hy flexion 
inttJ a head presentation, it is s[K>keu of as "version by the 
vertex." 

The ciLses in which version may be rwjuirod are: transverse 
presentations ; sometimes in he:id, fare, and hnxM-h presenta- 
tions ; (vrtain cases of nuMlerately contracted jwlvis; ami in 
cast* where accidentnl circunistancpM render rapid delivery 
necessary, such as plar-eiitn pr;cvia, rupture of the uterus, 
prolapsus of funis. <*onvulsionrt. te^lious lalwr, etc.. provided 
delivery by forceps is not stde or practicable. 



342 



VERSION OR TVRSISQ 



Choice between CErHAUo and Podalr: Version. — 
When tX)rre<*tion (tf n nialprt^t^nUUion is nil that is recjuired, 
aud circuin^Uinriii do »<>/ render hiilweiiucnt iiimieiliate de- 
livery uet-essury, ixrfonn cfiihiilic viTsion. Whiii rapid 
delivery w (iee«it*iiry, p4>dulic— briiij^ down feet, that traclioa 
may be made and delivery completed at once. 

METB0D6 OF OPERATING. — Eftcli of the two oi>eratiou9 
(1) cephalic, aud (21 podaiu^ version, may he periormed in 
three way H : 1. By exlemal uhdnmiiial niauipulaliou. 2. By 
combined external and internal niauipulation, tbf* Jjrujtrr/* only 
going into the oh uteri. 'A. By internal niHuipuIation, the 
tohoU hand parsing into the uterine carity. 

AutUrplir PrrjmrtttioH-x. — Before? niitf version 0|)eratioQ the 
a]>donien. thigbii, and external genitals of the wunniu. together 
with the hau<li3 and arms of the u)^rator, niu«t l>e made 
aseptically clean (as already explained, Chapter XII., page 
214) ; and when the fingers or hand are to enter the uterus, 
the rugiua and cennx uteri m\ist l>e firM thoroughly Hterilixed 
with the 2 p<^r cent, creolin solution, or the I : 4(H>0 mercuric 
bichloride sohilion. When the o|>eratioii iH (ione, and the 
third stage of labor coniplettMl, tlie utfriui and vagina muist 
be waahetl out with the creolin s^tlulion. 

Veesion by External Manii'itlatton. — ChieHy em- 
ploye<l for correeting transverse presentii lions, either l>efore 
lalwr Wgins; or, lalior having Itegun, before the waters have 
been discharge*! ; or as *x>n thereafter as p<j;!tuble, wliile ihe 
chilli is e4u>ily movable. 

It may aI»o Ik* done in breech cjiaes : changing the breech 
into a head prcsenuuion. The ntetluHl of changing a face 
preeentati(m into one of the head by external manipulation 
faa» alre>iuiy l»een deecribod under " Kace Treijcntations." 

Operatioxs in Tranrverke PREftENTATioNa — Having 
previously made out the exact |Htt*ili(Ki of the ehild, (head iu 
one iliac fo**!*a. br<'e<*h in op|x»site tlank), plaec the woman on 
her hark, with the lower liniiw rJlraifhl out and feet slightly 
apart ; unrovfr the alMlomen, and stand facing the woman, 
while the hands — one on the child's head, the other on it.'* 
breech — make tf/cuc/y, pfrviMciU prervure in a direction to turn 




OPERATIONS IN nREECIT PRESENTATIONS. 3-13 



the head down toward tlie l»rini and l»reech up toward tlie 
fuinUi.^ iift-ri. For rx:im|»l<^ : In ihfi (lurso-iinterior jm^iliun of 
a rifflil-ijliiujldfr prrjutnttttitut Cm^* Fi-.'. 144. j«ij;v 'JO,') |, tin; rijrht 
hariil will prasp tlu* head in tht* h't^ iliar iuswt, aihl t^eiilly pr*is8 
it down toward the puliett, wtiile the lefl hand laid Hat upon 
the other side of the uhdmiK-n, Willi the iinper-*'iids pnintiiij? 
toward ihe Uiiidun titpri, will piit>h th«* )>reerh (»I>li<nit'ly upirard 
and ti>waril the median tine. l>urin^ a [laiti !<lop iiiani[iu- 
latiii^, holdiii;: the eliild jnst tirndy eiKiii^rh lo retain any de- 
gree of ehatit;e in its |KJsihi*n ulrendy jijaiiied, PrfiViire in the 
intervals. When the child fi\i\K* round into ils rijiihl [voHition 
rupture the niendtranee (if luljor have l)egun ), that the woridi 
may contract and keep it there. If lalior have not bejirun, 
place two ]>ada — one on the nide td' the uterus high up againHt 
the breech, the other ott the opj>t»ite side lower down, jigaiu^t 
the head — and retiiin them with an alid(mii[mi tmndage. 

In thus hrinpiup the hruil into the [ttlvi.s rt'phaiir version 
is accomplished. Should there l^e any t'ufxiblin^ iiecef=siily 
for spesedy delivery. jKnlalic wn^mi t'hoidd Ik* done iuKtead, liy 
preesing the head up into the fundus and the bree<^h down into 
the pelvic brim. 

Operation in BREFrH Preskntationr — The woman 
having J>een placed in position as i>ef(»re dewribed, the ojKir- 
ator staindn on that side of her townrrl which the child'a abdo- 
men 18 directed ; for example, the child's back beinj: toward 
her right side, he stands on her leil. Hi.»* riirhl luind is placed 
on the fundus ntrri and the head prefpcti laterally and down 
townnl thf ieO iliac l'o«*a, while the left hand, placed traiiR- 
venndy alnivo tlu* pnhes (finger-ends |>niniing lo her riphl)» 
push the breerh laterally toward the right iliac fuesa. The 
chihl's U)dy having been thus made to l>rffiji the df^ired 
change, the pressure is (X)ntinued. right haml pret-'uing heaii 
down into the pelvic inlet, left one pushing breech upward 
into fnndu.*? uteri. Shouhl the beginning of the chungc he 
difficult to arf<ini])lish. owing to the hret^ch dipping' a little 
into the pelvic brim, one *>r two lingers nmy be |tfi.<»ied into the 
vagina, and the breech lifted altove the brim, while the otlier 
hand makt-s pressure on the head externally. As a ride, the 
prvsnurv U})on the bnun-h will In- more LdHeienl than that njKin 
the bead. The operation is easier in multipane than in prirui- 




344 



VKjisrox OR TURyfya. 



paras. After several suceewive failures to turn the cbilJ, tlie 
operation HhoiilJ be abaitdoncd. 

OrKRATiuN* IN Hhap Pki-«kntation*s. — Chani^nnp- a head 
pres^^ntation iiirj» a hreiM>h, t>y extenmi ninni)iulalion, cotii- 
priseH the m^uih* nit'lho.U (reversed » i\» tli(*se ju:?t described tor 
changing ibo breeeh into a head preiieutation. 

Pia. 173. 




BipoUr runilon (flnt step). 



Version by <V)MniM:ii MANtrii.ATioN. — AVhen verairtn 
by external nuinipuhalon in ne<:ei^»arily iuipotttfible, or hud 



VERSlOX BY mMHiNED MANIPVLATIOS. 345 

failetl artor trial, the setfind IraM dauKerous uiethwl, In' coin- 
liim^d nuiiiipiihuiiin, sliuiilil l>t' invt\. TIiih ^0Ilt^iHt« of t)iuni|m- 
latiiig ouLsiik' witli one hnml, while the other is ])iwfieil into 
the vagina, two or three nf it.*^ fi^^fffVA ouly j^oini^ iuto the 
idenuf. The huini untjjiile pushes* tlowu the part it is desire*! 
to bring to the -Hiiperjor Htniit, while the fingers inside simul- 

rvi. 179. 




BIpultii .^.J^ri-.h '^K'OTtrl slop). 

tflDeouslv muve tlie jmrt at the m out of the way and upward 
along the njijKjsitw fide of the ftelviH. Thus, in hfotl prri^cn- 
fitilunH, when it id desired to bring down the feet, the opera- 
tion conipristw three ste|ia: 

Oprmtinn of Jiljtofttr Vi'miou in ITeail Pr^srntatinits. — 1 . 
The Hngefti intfide lilt the heatt toward that iliac iht^ix tovvartl 
which the occiput [wiuts, while the liand outride depresses the 



346 



VERSTOK on rvRyixG 



bre«*h along the nppiieite m\e of the womb (Fig. 178), Thb 

havinp l>een done — 

2. The fingers inside can now touch tlie shonltler, und they 
push t)r lift it in the same direetiot* nn (he hem), while the 
nund out^^iile still iurlher depresses the breech ( Fijjf. ITJ*), 
The heud \s now a litlle hij.'lier above the brim than th© 
breech, and (he kue«; in within reach ol' the lingers. 

Flo. ISO. 




Bipolar versinD ftblnl step). Tbefxtomal hand, asahown In tbcfijpire, has 
not y«t changed lla poflltlon. bol is ready to doao. 
t 

3. Om«p tlie knee Mho njend)runes, if unbroken, may 1)6 
ruptured) and pull it down, while the hand DUtFuie changes 
its pimtiuti wi as to push up the hrad toward the fundus ( Fig. 
180). The foot niny now l»e reached and the case managed 
na a breech or footling presentation. 

Ill tmnm'rrff /^rrv»r»Ar/i'mi/* the o]iernti()n <y>mprifte8tbe pecond 
aut[ thinl 8le(Kt above given for head i-nrn-h — ihiu is, push the 



ISTERyAL VEHSION IN HEAD PRESENTATIONS. 347 

BlmnMrr after the hea<l, then frrasp the kuee, vU: Should it 
he »ie?*inKl, however, to convert the shoulder (tninpvcrse) prc- 
sentiitinn into a hfntl |ires('iiiation iiiKiiMid of a tbotliut^, the 
Iin;^ers inside will, of course, piisli the nlioulder in the dire*'- 
tion of. and ttftrr the hrefcht while the hand outside ilepre«ses 
ike heoii tuwurd the [)elvic brim. 

Bipolar Version in Face PKi2^ENTATiON.^Oj>eratioa 
is essentially the same as pro\"iously describoil far head pre- 
sentation. The iin^^ra inside, durinir the Hrst step, push the 
face toward that side of the jK.dvis op|Kwite the chiu — f. «., 
they lifl it on to that iUac (oeua t4)warid which the forehead ia 
dircM'ted. 

It should 1h? particularly ohserved that the mahi purpose of 
this comhin<Ml or " hipolar " method is to supersede the more 
daujferous proceeding of introducing the whole hand aud part 
of the f()re4inn into the uterus, which it? the only niotle of ver- 
sion remaining when the exlenuil aud hi]>olnr TiicEhoda have 
l)een unsuccessful. The bi]i<dar melliod can l>e done before 
the OS uteri ia sufficieutly dilated tu admit the whole hand. 

Version nv Internal Manipulation. — Tike all the 
version oijerations, this is comparatively e^isj' before the waters 
have escaped and when the uterus is not rijjidly contracted 
round the child, but difficult when op|H)site conditions prevail. 
Additioinil conditions, however, are neces8(iry l>efore the 
operation should l)c attempted, viz. : the |)elvis must lie of 
:<nfiicivnt size to admit the hand ; the os uteri must l>e dilated 
or dilutable; the head (if it present) must not have pa.4.*ted 
throtijrh the o."^ uteri, and the presenting part (whatever it 
may l>e) must not have descende^l so low or lM_MX)nic so firmly 
impuctetl in the ]>c,lvis that it caimoi Ik* pushed back alwve 
the su|>erior siniit without rii^k of lacerating the ulero-vagiiud 
junction or other aotX parts. 

Internal Verhion in Head Presentations. — The 
Operalion comprises three slej* : 

1. IntriHJuce the hand and grasp the feet 

2. Turn the ciiild. 

3. Extract the child. 
The first two steps arc to be pmceoded with only between 




348 



VERsroy on rrrRNiNO, 



the paius; the third step, only dxinng the i>fiiu& When a 
pnin conips on dvirintr the fh-si two p«rts of tlie i»|)eratiou, hold 
the hand still. rthixe<l. ami lUit, and thus avoid risk oi' ruptur- 
ing uterine walls with llie knuckles. 

Ojteratwn, — -The woiiiau is placed on her hack, the liije 
hrought to the edge of tlie lied, the legs properly supported ; 

Fig. lAi, 




Pwlnllc vt*i>inn : Knupliig the feet- 

tlie of)eralor nits hetween them on a low seat If the womb 
be iirmly contracted and waters discharged, complete ana»- 
thiwia i^ rc<juiri'd. 

tiare the ami to aliore the elbow, and anoint it with car- 
Iwlized vas<'linc on all pnrtft exrcpt (he hund's palm. Use 
the baud whuue pului currespouds to the al>domeu of the 



INTERNAL VERSION IN HEAD PRESENTATIONS. 349 

chil<l. viz.. ID the L. (). A. and !>. O. P. [lotiiliuug, the left 
hniwl ; in (he U. O. A. und U. O. W [msiiious, the right haml. 
The fini^tT-entis an* hroii^^ht to u ame over the end of (he 
thumb, and the hund inlrodured into the vagina (with a 
slight rotatory movement, if iieoessary) in the axis of the 



Pm:.1S2. 




Podallo vvrsloii -. tunUiit,' tlic elilld. 

pelvic outlet, its l«u*k townnl the RatTuni. The fin^r ends 
an<l hand are then pres^'d on into tlie iw uteri, tlio elbow 
l»einjr depresses! toward tlie jMrinriun so as to brint: the Imiid 
in line with the axit* of the brim, uhih* the niher hand resets 
oultride, making sup[x>rt and eountc'r-|irL'MUre upon the fundus. 
With the thumb between the head and puboH, and the four 



350 



VERSIOS OR TURNDfO, 



fiugura between the head aud saoruni, the hea(i 'm ^rnaped and 
liAed out ol* the way, "on the shelf" of that jliiic tosfia 
towuni which ll»e oivi)>ut |KiiiiU. The wrist rtviinur uguiiist 
the foreliead kee|)w it there, while the hautl pKW un U|i to ^rasp 
(he feet, the other hand eoutiiiuously Bup|x)niug the fundus 
(see Fig. 181). 

The feel (one» or Ixith if ]xw«iihle) are then drawn down, 
while the other hand dej)reifi*es tlie hreeeh. whieh l»egiiis the 
sero/ir/ Htep, or turning the child (see Fi^. 1^2). As it geta 
partly round, the hand outside may ehan^e its |>o«ition to push 
up the head. Tlie latter huviii^^ rea('he<i the fundus, turning 
i» aocotriplished, and (Hd) cHitAciion {tiurtntjtUe iMuns; maybe 
eunipleled. fo11uwinj|r the mechanism luid luodts of delivery 
already describe<l tor hreech ca^es. 

Should the membranes he unbroken at the I>eginuin^ of the 
o[)eration they should l>e ruptured when the hand pu£Be« by 
the hnul into the uteruH, the wri.^t artiuf^ us n plu;; in the. oa 
to prevent ee*oa|>e of wuten; ; or the ban*.! may be [la^eeil up 
beiwren the unbroken mend)rane» anil uterine wull, ihe hug 
l>eing ruptured when the feet arc felL The lutler method is 
object ionable, from ri^k of looeeniug placenta, uuleae the 
operator l>e skilful. 

VKRStoN BY Internal Manipulation in Transvkrse 
Prikkntations.— This proceeding comprises the same three 
8te|w as just dewrihed fur head ai!*es, and the same j^reneral 
rules of operatinj^, with nioiliticationi* now to Ih* notetl. In 
selei'tiuff the hand (the woman lyin^: ufvu her back), use the 
right hand wlien the right Bide (shoulder, etc) presents, and 
the lefl for the left »ide. 

Where to Find the Feet. — In the right phoulder or 
ann "presentation," when the ** jxwition " is dorso-«»/mor 
(/(•y? cephnlo-iliac), it is evident the f*»et will lie found ti^wnrd 
the right and }H}«trr\or jiart of li»e womli, alK>ve the right 
gan'O'iliac tfyitrhomlrt^siti, heni-e easily readied bv |tii8sing the 
right hand niotig the hollow of the t^crum, U) tlie right uf its 
pronionturv, and then higher, toward the |HMiterior part of the 
right iliac ftks.sa. 

lu the ffjt »houIdfr or arm priTteiUation, when the |»(J8itioo 
\b donto-antrnor (right (vphalo-i)iuc^ it is evith-nt the feet 



WHKRt: TO yihl) THE FKET. 



351 



will he toward and alwve the lefl. wicro-iliac syaehondrods, 
hence easily reached hy (»assiiig tlie letl hand mi tlie letl side 
of SJirnil |>r<)iiionlory, etc. 

Thew doi>i>-«;i/rj7V^r |nit*itioD8 are far mure frequent than 
dorH<>-y>/M/<'r/«/- ones. 

Ill the do^^!o-/wfl/*f/*1or {rifjht ocphalo-iliac) "posilion" nf a 
right shoulder or arm " prtN*eututioii," the feet will rest towiini 
the /t-jt aiul anterior part of the iiierii.s alMtve (he left aeetat)!!- 
]uiD. The right biui<l, therefore, f^hould Ije pa^eed along the 
eacnim as l)eforc, hut to the /r/V side of it^ promontory, and 
theu higher up toward the jxjHterior part of the frft iliae fotssa 
(where it feeU the hack of ibe chihl's breech), and munt then 
he protittied ronud the breech^ over the thigha, toward the 
anterior part of the Ujt iliac fossa, where the feet will be 
found. 

In dor9o-y>o^<Ttor {hft cephalo-iliac) position of a hfl 
shonldcr presentation the feet will rest toward the ri(jhi 
anterior part of the ut«rus above the right ucetahulunt. and 
wUl he reaehe<l hy the left baud going behind and prouatiug 
round tlie hree<-h a.** before dewrilM^d. 

There in another riUMle of reiiching the feel in the two 
d/)rsthfMttitet'lor [positions, viz., by jia.-^inu; the hand direetly up 
to the feet l>ehind the pulnv and avelalmhnn, instead of going 
behind the chiM'si breeeh and pronating round it Thia 
methoil iH made eaj*ier by phu^ing the woman on her Me (the 
ffldp tnwani whieh the feet are dire<'ted), while the operator, 
standing behind her, |»asM^ the hand ( right one for right lateral 
"preHeutation/* and hdV one for Wf\. as l>efore Btateilj, with \\a 
back toward the pubfA and acetnbuUnn, direilly to the feet. 

}Vkirh Jmt U} pull iloifii. — From the infrwpiency of trans- 
verse preHi'ntations, only conipanUively few oj>erator8 have a 
siiffieient nund>er of casefl to formulate rules ba^ed on their 
own ex()erienee, and thus**? who have (K> not agree; some pre- 
fer one foot. 80ine the other, an*! find theorelient rrjuwms for 
tlieir choiee. No fixed t\\\v» ran lie i^tate<l : much def)enda 
OD the oonditiont* present in ea<'h raae — whether difficult or 
easy, whether early or late, whether witli or without aonie 
preskiifig ueeewsity for hiirte — and a great deal de|ienib n|K»n 
the acMjuired t^kill of the o|i<Tat(tr. 

It iit |)erlmjM bt*i«t to get both feet if this cao n-adily be 
done ; if not get one, ami in ditfienlt ca^es with previoufl 



3o2 




VERSION OR TURNiyO 



delay, discharge of the liquor amnii, rigid uterine contractiun, 

dnrijrcrs from lit in(»rrh}ifr*% iiii|H^ti(Iinij; ru]»ture, or st^nie other 
pn^w^iiig I'cuf r^^t'iu'v it i*- iK-ihujw iietttr to tjet iht fiiH one ytxH 
ctiu ftui, niul rims avoid risky of delay nud prolonged nittuipu- 
lation iu iiiakiii;: a ikdeclioii. In ea.**}', early ^a^etf, either toot 
will do ; l>ut n j^killed ojiemtor woukl prefer to seize the one 
diagyiinlly uppu^ile the presenting arm or shoulder — L f., if 
the rijLrhl ann pret*4.'uU seize the left foot, and Wee versd : thia 
makes turuinjr eib^ier. 

Iri tnini^verHe ])re]!(entations, when the child haa been {umed^ 
the ca.'se may he left to iialiire, unlei« rirt'nnwtaiiees render 
rapid delivery neee«8ary, wlieii the third Htep of fxiractum 
may he |>ertorme<l. If it i^ to lie left alone, only one foot 
should l>e hrought down, sip that the luitiuek of the other side 
may add to the size of the bree<'h anil produee adetjuale 
dilatation of the oe, ao as to i>crmit easy j-nifiRage of the aller- 
comiu^ bead. 

Cephalic version by internal manipulation iB not |>Grfonned 
nowailay:^, owing to the difficulty of fjjratipiiig the globular 
head and for other reawus, (hough it was preferred to jnxlalic 
in former tiniee. 



pROLAPSi-: OF THE Arm. A ta|>e niuy be put upon the 
arm by which an aamihtjint hohl^f it exteniled in the vagina, 
while the o|>erator'a hand passes in to |)erforni intrrual ver- 
Hion ; but it muHt not l>e held by the ta|>e so tightly aa to 
interfere with it:* upward recegsion when the feel are being 
drawn down. Traction on the ta|»e may ajpo l>e used to 
deliver the arm and prevent its ascending alongside of the 
head during extraction of the brMly. In jHTfornung bipolar 
veretion the arm may PometimeH be ur^ed to advantage iu pxuih- 
intj the ifhoulder in the direction of the head, an before eat* 
plained. 

DiFFicui-Tli-B OF Vkrsion. — The external and combined 
methwia of version, when they can be acconij)Iis'lie<i at all, 
are done with companitive eai*e, and only in the more favor- 
able vmti'n. They would ^-arcely be attempteil and seldom 
i?Uf*ceed in the more difficult cases now to be con9i<lere<l. and 
iu which even internal vcmon is anything but easy. 

The mo8t (*onimon diHiculty is evacuation of tl>e waters and 



DIFFICULTIES OF VFIiSlOX 



353 



riififl t'onfradioti of the uterun arhimd tlu- chilil. The mflnj|m- 
lutiuut) iiKTeiwe uterine i:|»aHiii gtill more ; the (>|)unitorV iirin 
becomes craiu|>eU ami ut^U-su fis^ni presj^uro; tfw rUiltt will 
nut tiiru : uiul lIutu U grtiut rink of ulvriae ni).)ture it' violcuce 
be fniploveii. 

Trralfiifnt: Complftc aii:wilht«ia to rWax thi^ womb, and 
Pteady, fjentlf, |jeriH.'vering etibrU on ttie part of tlit* i)[w'rator. 
SiioiiM lht> 0]H'rat4)r'fl hanil becouut iiiiinlM?il ami iis<.'K^sh, it 
muft be witlniruwn lor reciH)eration, ami n-iiitroiliuvil utltr- 
ward, or iu iuit pln<^ the band of a skillid iL-;sismiii naiy l»e 
rtjsortfd to. 

£veu whcMi the r<K>t hiui been drawn down to llic us uteri, 
the shoulder (or beiuJ, an the Qiisa may Iw) will not recede, 
and turnini; aeenis imptwsible. 

Treatment : FilsIcmi a ta[>e to tlie toot, uf suffitient length 
to be behl outride tlie vulva, ou which Irm-tioa umy be made 
by an aKsistnnt, while the hand iit.<ide piisbe.s the. he^ul for 
Bhi>ulder) iu the pro[»er «lireelioii. lu shoulder wises further 
assistance may l>e reiuiered by t'xU-nuti upward pres«ure of 
the head. The iateriial repretwiou miL-^t K.* made with vx- 
iftvt€ cantioiu to avoi<l huvration, etc. liy g^riLsping the arm 
near the ellww, the shatl o\' the humerus rimy be used to 
make upward pn^isure iu the ffleuuid cavity of the shouUler. 
Whei» the prcseuliur; jiart, whatever it may l)e, will not recede 
sutiicieut to admit the oln^tetrician'^ hand, placing; the >^onian 
in a fftniu-ptTtortU jwsture will be serviceable. Ko com; should 
be con;*idered im|M)«wibIe until thin ]K)sHirc haii tie^m tried. 
Again, by placing ijie woman in a snjuattin;; [M>!iture (provide*! 
there Ix? no cumlni-indicntion (o it, iw rni^ht cxrur from ^rrtnt 
exhauilion, et*^ K the pri^sure of her own thiulm u\)ou the 
al>domeu nuiy lift both wond> and child, and ihitft He<*ur(* the 
dei«ire<l receaeion of the prcHcuUnjr part. Should nil eHorts 
fail, eml)ryoloiny Iteconiet* the unly resort ; or. if the cliild 
he alive and mother in ^(»o<l eimdition for the ojieralion, 
syinphy.-^otomy nuiy be done. 

After turninjf, eximditin may be difficult. Traction on the 
lower extremitie* should Ix* made slowly \vhe4» the 6f>fl i^arti^ 
are uot yet dilated, it in nnneiVHsary to alteinpt lit aid rola- 
tioQ of the btji** — the lej; that i?* 'lown will 8[)ont.aue<iUi<ly (.xnue 
to the pul»es. When hi|ja lx.*;^n toemertfc elevate lej(, or loirs. 
toward pul>ert, that the |Mjt»terior hip umy eecnpe first ul the 

25 



354 



ViCRsroN on n-nyisG. 



perineum. lu grasping Uie fhiltrit body afl^r ileliverv of the 
l»re*.-ch, grasp i7^ prfn*, not the soft slrurlnrt-a above, which 
might injure the viscera of the alhJoniL'u. The hi|ie and the 
alxlomen having l>een delivere*!, the nnns come uexL 

Krtntfiion of the ArniA. — Delay with the anus (as witli the 
after-coming head) is fatal to the child — ofWn within ten or 
tifUvu minutes ; hence different methods of extracting arm 
should, if necetuary. Ik* trietl in rupitl sncce^don. 

Anns Fhxeti. — Normally, amis remain jiejretl on chest, the 
elbows pointing down toward tlie breech. Here delivery ia 
usually easy, thus : rotate IkmIv of child to bring one :«houlder 
to ptibes, the other to sacruni ; |>ai« in the haml whose |>alm 
CfjrresjMmiis to the child's alnlomeu up to the chest, seize the 
foreanii, as near tiic wrist jis jKjssible, and pull it di.»wn, the 
delivered {tortiou of the child's IkkIv lieing me^inwhile lifted 
up and toward its back, thus giving more sjmce for the oper- 
ator's hand over the alxlomen. Posterior arm to be delivered 
fint 

AnM Extemh'd, — In version cast's when tra<-tion is made 
cm breech, arms get displaced ; they catch against sides of 
])elvis and become extemled. and [»oiut straight up alongside 
of the hea<l. Ofyrn irry (tijjini/t to (irliiTf. 

Trrntmrut : ^^ ith one baud lift the legw and l)o*ly. as far as 
fX)(silile, upward over the pubes, and to one side : this will aid 
the posterior shoulder to desc%^nd ami give txkhw for the whoU 
hand of the oix-nitf^r to |iase into the vaginn along tlie hark or 
«w/cof the child, until two Hngers reach the ]KiPierior shoulder, 
and then slide along the arm to the clboiv, which is pushed 
acroK^ the child's face and brought down over its chest. If the 
Hugers catmot niich the eibouu pince one of them lengthwise, 
on each side of the arm (where they act as splints t<» prevent 
fra«1ure) ami push hunterufi across face and chest, as In-fore 
(Tig. \t^X} 

if this etf(>rt to deliver with the hand |»a.'**ing in along tl»e 
haek or Aide of child fail, withdraw the hand «ith<»ut thday, 
lift tlie chihKs IkkIv t<»ward the op|MMqte side ( but still upward 
over puUv) and piu!« luiud in along abdumen of child, until 
two fingers reach elUjw and luntk it furwaril over face and 
chest, as U'fore slaie*L If lime allow any choice, the hand 
shriuld l»e (mwhnI in l>etween the |Miins. 

The podmoT arm having liccn delivered, the other — 



n!i'FicvLTn:s of version. 



S55 



direct^ onienorhj lowunl the piiln?!* — iwmi be extracted, 
thus: In stmie t-nst-s ilcpri.s*? i-liildV IhmIv. oh far lu* |MWi.silile, 
toward |ieriueuin ainl lo urif ^idt^ wliilt- the tUKTator'ti liaud 
|«ii*fk's in, eillier nloiig buck nr itlnhnnvn (try bolli ii* oiio fail) 
until reiicliin^ effMtn\ wliit-Ii is draMii hy tsvo HiigiTS HtrriHSS 
face aud cbesl and brought out under jmbes. (Fig. lti4.J 

Pia. 163. 




Drlirory of poot^rlur unii vrlion extended. 

Anoiher plan : Instead of trying to t'xtmct anterior arm 
umler pubti, or haviui: failwj after trial, rotate undelivered 
arm to wi'Tuni, where there ii* more room, and deliver as if it 
ha<l Ihh'Ii ori^rinally posterior. Thig rotation is uirouipli&bed 
by M-izint^^ rtdenMnl arm and drawing it U[) along one ^ide of 
X\\v |M'lvi»». frnm rbr rMierum lo thi^ pubex: the shoulder innido 
follonn I hi- ninvruient and gm*;^ to I Ik* Nieruin, when it is 
dotiven^l ill the name way, but niori> eJintv, than the firrt. one. 



36G 



jSVirtw/f/frx Trniiftver«€. — lustead of rotating into autero- 
IKif^terior ilianiettr, shouliierj* sometimca retnain transverse. 

Trt'trimeul: iWiwy tborax in both hatids and rotate one 
gliouldor to 1*1*0111, oi)^ to rear. Kailiiip in ihiji, if" l>ack be 
toward putx's, lit) body njmani iiml \nii^ hand along uhdomon 
to seize ell>ow, aud liriug it duHu aorucH imx*, etc. If back 



blu. 




TVItvory of Ulterior tnu when extMidrd 



of child he toward m4mtm, the anns. if ftered^ may be drawn 
out under pidx* ; if rjiendrri, this will be difficult or im|>ofipi- 
Trv. then, to )m8b hand Imck of cliihi and ilraw elliow 



hnrhvitni and flotrmranl alonp ami Itehjw ><ide wall of pelvic 
then ptijth fdiearm nvvT ilmrax and draw it down. 

Dorml Duplact^ieid of th« Arw^ a« »hoWD iu Figs. 186 and 



DIFFICULTIES OF VERSION'. 



357 



186» may occasionally coni|ilicutc exlrartiou. This may oorur 
in tuit waifH: The arm haviii^^ het'ii cjiemied alongnitle of 
heuil, the elhow lHH*<»nien l>€iit, throwing Inrwirni ht^liind ueck, 
below <H'cipiil. wliere it cntchw u|)oti lirini of jx^lvis and 
nrrwi^ proirreiu;. It is <*aiise(l by rot:itin|; the chiM's ImmIv, 
the arm tailing to i'olluw this rotation, an<l is treaird by rotii^ 



Fia. Itt. 



Fio. lac. 




Donftl dlipljusemtnt of thr arm. 

in^ the chihra Uwly hi the opi^osite direction to the rotatioo 
that pHMluoed the tli»iiluceinenl. 

It may also occur i'nmi the tannic cnu^i when the arms re- 
nmiii ff'Xf'tl arr'>tv the fhi'Ht. and is fhni relieve*! hv pnfisitig 
ID the hand alun^ the bark of the rhild and griiifping thu 
elhow, which w pulled donmtcatd Aud forward; or euuply hook 



358 CUTTIXO OPERATIONS ON THE MOTHER, 

a finger iu the lieud of I he elliow aud push or sweep it later- 
ally aiul torward over the chiMV Wxca. In the ra.<o ehuwu in 
yig. l«o the fiiijLrer would thiiH wweep the elhow and forearm 
toward and over the rifjhi ear and nde of the head, uutil it 
got them \i\ frout, over the fa*x^ anil rhe.-<t. When it occurs 
with the arm fiexet!^ the R-apuhi will \x>, t'omui near the spinal 
column; when oeciirriiif^ with rxhmfiou, the seapuhi will he 
foreed auniy from spine ; hence diapnot^iti of methods to he 
use^I. 

In version casee, after exlractiou of the shonlderR, the after- 
coniinjf heaii is to l>e deliverHl hy the methmU already dtv 
scribed uudur breech prcecutatiuu (pages 2i^4-300^. 



CHAPTER XX. 



CUTTING OPERATIONS ON THE MOTHER. 

The cutting operations on the mother are : HyraphyBeotomy ; 
C;esarean Se<*lion ; I'orruV Operntion ; the Porro-Muller Oper- 
ation ; (.Vi'liotoniy ;' ( Vrlio-elytrotoniy.' 



8ymph^'8EOTOMY. — (Si^ultian operation). — An ojieralion 
invented by Sipuilt for eidar^n^r the jtelviH, by dividing the 
EtytnphvBiH pubis and sepnrating the pubic boncH from eftch 
other. It wafl tirnt practit^il ou the living woman by Si^iilt 
in 1777. Sitire that time the ui»eration bus l>een retjarde*! at 
different fieriodH with ahemntiiitr favor ami up[M)silioii in 
Euro]>ertn ciiuntrieti, but waj= never performe<l in the I'nited 
States until IH!*!2. In September of thnt yciir attention was 
called anew to the ^oihI ret'ults obtainetl by improved methwle 
of doinjr the o(>eration under aniiw^|»?iH by Dr. Rol»ert P. 
Harris, of Philadelphia, and tiulM«e()uently the utility of the 
procee^linji ha» l)een practically denionntrateil in thii< and other 
countriei*. and is now genenilly re<*opniiMNJ. 

I TliL< term C<i.-1ii)l«jn)¥ ifnitn Kutiui^ the alul niirn) liiu Ih-iii lat^y sulnitiliited 
for Iji|t«r<>t<ifiiy (fWtin /^ipani.thi' (Innlc or hollow of the wjidl). ('Aoitti(inu>a|rc 
■lUI ftcourU* A slinilar (ovAning to Luth tvrms. Cu'liotomy ia tbc more correct. 



SYMPHYSEOTOMY. 



359 



When the symphysis is Hivi<le<l during Inlwr {\\i- pubic 
bonee s[)ontuiieuti>4ly K^panite tVoin eu<'h oilier to tht* exUnil of 
an inrh or more ; they o[M'n like a puir of il>l(liii«r chmrn, of 
whit'h the ijiU'riHliat! syiK'h<nnln>ses rt'[ir»..s'iit thf luti^t'8 ; by 
seiMiniliu^r the woniau's K)>ver liinl)t* tht* j^ap may Ik- iiicr(:'a.m*<i 
to two. two mid a half, or ovuii lhr(^> iiichei^^ Ixit »m wide a 
separation as three inehe:, \^ not usually :idvi>a!de or neciw- 
8ary. Shouhl either of the saero-iliuc- joinl.s { hiritres ) Ive 
nncliylosed, and cuuwfpiently iniinovjihle, the ojKTUlioii eau- 
not lie done siK-t'essfuUy, ami is eontra-itidieatfd. The fhild 
i» delivere*! — u>iuully by foreeps or version — iinineiliately afier 
division of the pnhie joint. \jOfi» freqncully the natural |M>\vera 
are suttieient to aeeomplisii ilelivery. 

After division of the ityniiihysiH the puhU- l>oneit not only 
separate hU-i-ally, hut the- two halvit* of tlie now divided 
pelvis (more exactly the two iiniDininate IwineM. owin^^ to the 
jK'Ouliar structure of the samMliue Hyuehondmse?*, have also 
an ftnti'rior dip — they ^o down a little in froni, toward the 
|H'rineuni — thus movlnjj: the anterior wall of the pelvis farther 
IVorn the saenil promontory : the line of lite et>nju^ate iliam- 
eter of the hrini Ijeoumes more tihtntiu;; — more like the "dia^>- 
iial " eonju^^ate — and in tlierehy lenifthened. This descent in 
the anterior part of (lie iniioniLEmtti turner is farther increased, 
by pre^^sure of the lieail durinjL; lalwir, 

('«,S(-vf SniOibk' for the OptTfUiou.—iX} Cimfraded prlvrn, in 
whieh the true eonjugate diameter meajiiires l»etwe»*n two and 
three-<juartera and three and one-f{Uurter inches ( 7 U\ H.2 em.) 
— the ]>re;rnaney having, of eourse, reaehed full term. By 
separalion of puhie Iwnes the conjujrate is len|r(hened nliOHt 
half an ineh, while a further gain of aboni one-fourth of an 
ineh is awpiired hy the prfsentinj; part proIriidipjL^ hito the 
gap Itetween the divided Ixnies. In *' ffaltenr^l" jxdves, in 
which the h'ansven*e diameter w relatively wide, the lower 
fii^ure — lW(» ami ihreo-quarter inehes — may, after symphvse- 
otomy, admit a liviti;^ child lo piuss. In '' genemllij coutmHed*^ 
pelves the hiicher fi^^ure — three and one-quarter inches — will 
he more ueeerwary. In holh kinds of pelves symphyseotomy 
prodiK-es also enlargement of the transverse and ohliipie diam- 
eters. In fact, these two diameters arp len;^lhened more than 
the conjugate ; thus, when the puhic hones sepnrnte two and 
three-cpiarter inches, the ['(nijugate will bo increased half tin 




360 cvTTi.sa oPKnATwm as the motiikh 



iuch, the (tl)lif|iie one and oiu^-tliinl inolitti, aud the transverse 
one and oue-tit^h inrhc^ or theix*al>outs. 

(2f (*iii*L'(5 ill which llu' chihi ii* ujHiifitaihf ianjr, or in whifh 
it ho:* l>e<'<)?ne imiinr/ni fr«»ut taidty iiie*'hahisni, h» iu (irtrjttrfl 
ifieiittt-jHititrr'tor |tietiti(>ns i)f face nusen, aii<l oceipiiit-intMn'uir 
|K»*itifHi» of head |»res*eiU«itio!in. AIhi nrresited eases of liri'tvh 
or shoidder |)re:*eritntionP when nsiial nullio<l'» of (U-liverv fail. 

(.*}; Il in evident thai eouditions mentioned under heudin];^ 
( 1 ) an*l ( 2 J may ntexirt and Htlll he rfiiilahle W^v the oi)eratioii> 
but with h'm pmsiKH't of sw'<*ef»p in wmie inptaneen. 

In order ihai the ojieration shall Aueeeed certain other con- 
ditious 8houhl he pre^nt in every ea^ie, viz. : 

in) The OS uteri nitiwl he Mttffinrufh/ (fiJatal l»i allow rapid 
deliver)' arter jsyrnjthysis \> divided ; or guffitiadhf dihitible to 
aUow rupid dilatnlion artiticiully. 

{h) The child must l»e, no| merely t/iiv, hiiti«<» far r^/iinjurcd 
hy delay, or liy previous attempts to deliver, il* to give it 
every chance to survive after lurth. 

(r) The mothrr sllould he in rfttorl roiuHfion : tieitlier ex- 
hausted hy delay and exertion, nor injured hieally hy fruitier 
attempts to deliver hy other mt'lho<is. She must l)e free from 
Bt*|itie inf<H;tiun. 

The 0]H*ration is ronfirt-intfimtrd when there is anehyU»pis of 
either sarro-iliiie joint (hence in the ohiique |Kdvie deformity 
of Naejrele, and Uoherts' ftelvi?! i ; in all nts<?s when the con- 
jupale is /*"a^ than "11 inches — presumini: lln' child to l»e full- 
Mzet\ ; in cases of iwny, <-anrerons. tihroid, or other tumors 
iM*cupyinjr llie jtelvic canal, etc. Anchylu":is of the pubic Joiut 
itwdf d«jeH jtot nei*eS8arily <*outm-indicate the oiM^raiion — a 
ehain-eaw Iwintr in readine?^a to ro|)e with this difficulty. 

Dautjtrti of the OpvnUiott. — Heinorrhaire from the wound ; 
hu-eratiou or other traunialisin of blnilder, urethra, and 
va^nna, and niihw^pjent tistid:i-: impaired loconmiidn fmm 
faulty union of pnhic hones and injury to sacro-iliac synchon- 
dnises; w'ptic infcciion of w<iuiiih All nf these have oc- 
curred ; hut ifnpn)ved nit'thi>ds <»f ojH'nitiii^ are irnuhmlly 
rwlucini^ the fnvjuency of llieir (srurrence. While the ma- 
tenuil mortality durinjr the last few years has been about 12 
per cent., more recent results, owintj to improvefl trrhuirjue 
lutd makinjr the o|K'ration an "elective" one insten*! of n Inst 
'i, show a ditninisheil niortalitv and indiciite that in ftiture 



SYMPHYSEOTOMY. 



361 



the (leiili»-rat« may Iw rtMhice<l to uo(hinrj uuder favunililc 
ciri*uni;ilaiipej». The infant ni'triaHhj in not iii<'rtMU<<.Ml liv, iiut 
Inrj^'tely deiH-mbi u|>on tlie (.'oiiditioiw pretvdin^, iIh" operation. 

Jiijffnnnetitj^ «x<m/«/(/^, eU\ One ni«.sii(tiiut to give the ana'S- 
thptic ; one to hold n ratlu-tt^r in tlie nretlira, and otlitTwif^e 
aid tlu' o|»erntor ; a nurse to take charge of the child ; anotlier 
a-ssi.siant nmy he ndviwiMe to j*eure uterine eontraelion and 
retraction, and delivery of plac*'nla. 

The iu.Hruuieuh necessary are: n scalpel; a prohe-pointed 
hi.Mour}' (the latter in phu'c of (lulhiatiV or Mori.-'aui's knife); 
a disnecting f»>rce|)s ; half a dozen artery forcepH ; iitedle- 
holder and curved nt^<lle.s ; a metal female catheter ; a chain- 
8a\v ; pntures of pilk or Hilkworm-^'iit : iodoforni jrau/.e ; liga- 
tnre«; Hlri^is of adhci^ivi^ plaster two or three inches wide» 
long enoiijk'h to go round the |)elvis; a utrtmg hinder or ab- 
douiiual l>audage of inelastic material ; together with io<It>- 
form and the iwiial material.-; fur imtipeptic dresfnnp, and a 
pair (if olwtetric forcejjH. 

Operation. — The mellnxl of operating is still undergoing 
revision : necewijiry m<MlificationH and imj>rovernenti> in its 
tef'hnit^iif have heen added during the last Jew yenrs. The 
pulK^, lahiii, nnii |ien!UHiiii are nhaveil, and, togetlier with 
the ahdnineiu tliortniirldy disinUn-le^l by wxip and water, 
bichloride dilution, etlur, etc.. a-* in any alMlominal section. 
The vagina uIh) w thonnighly sterili/^l with a bichloride 
solution 1 : -ilOO. The wonnm is anesthetized and place<l on 
her back near the e<lge of the bet). Sune <»perators stand by 
her side ; others prei'er to l>e in front between her lower limbs. 

The bowels must, of coun*e, have been previously emptied 
and the bbuhler e«tbeteri/e<i imme<liately before commencing 
the o[>emtion. when it will also be advi.'^ble, by a final aua- 
eiiltation, to ascertain jMinitite/tf that the ebibl is still nlive. 

There are Ino uttf/M of doing the openition : Jirst^ the '* r/oW*' 
or ** mibriiiaveonj*^' methwl, with a itltort incinion ; geronfl, Ihe 
"/);)'*n" method with a iong incision. ICach has its advan- 
tages and disadvantages: some operators prefer one, home the 
other. The rlitnvti method with i*hvH incision is generally 
preferred) ; as will presently be seen, it enlniis U^as danger of 
Feplie infection of Ihe wound from the lochia, and let« riitk of 
hemorrhage. 

Subrutaneotis method^ with bIioH iTicitnon. — In the median 




362 CVniSQ OPERATIONS ON THE MOTHER. 

Hue of the alidiiiiifn, uii iiicit«iuii '\6 nia<]e one iiml oiie-hulf 
iiichtA lorijc (wime make it out., others twn inches) the fotvcr 
en(i of which is half an iiu-li alxivr the upper emi of the 
puluc sviiipliysiiy. Cut through ik\\\ uu<l f:iM-itu, ilowii to the 
ret'li imis<'lejj. Tlu^ fitlacluiU'nt.H of these nuiwlns are aepa- 
rate<l from the jMis'teriur suriace f»f the svinphvsis and puhic 
nimi, with the iirijri'r, whiih is passeil *hjwri ht-liitid tho joint 
until it can W hooked under the puhie areh. Tlie a.ssir'taut 
now pawips a inelal ratheiiT iiilo the hhidder and hfthls the 
iirethm hiiekwani toward tlie riLchi side, to kuep it out of the 
way wlule the joint is l^eing divided. 

The Hipkle-slm|>ed kidle of Galhiati CFig. 1^7), or what is 
juat ViA good (or helter in some aiw*; a prol>e-]K»iuted, slightly 

Fig. i»t. 



^^ 



OAlbUtl'fl knife for symphjrscniomr. 

curved histouiy, is pawi^d down, fjuided by the finj^er, tiehind 
the articuhition and hfj^tkeil undtT t!ie suhpuhir li^'ainent, 
when the eartilaKinoiirf aial li«rHmeiitous tissues of the joint 
are eut from behind forward uiul from helow upward, until 
the bonei^ separate — sonietinK*,-* with aa audihlc irark. The 
juint iH not fiUitjflff to Iw severed in this parlii'idar nmnner. 
The point of the lustonn* may l»e ;ruided hv a May's director 
(previously intrmlnced) instend of the iinger ; or. ajr:»in. the 
bistoiirv nionr, iu |M»int kept el««ely in eontact with the 
artimilation, may he passed <iown. iruided hy a fiuL'er of the 
Other Imnd in the vairina. Atc«iu, the joint vmif he r^evered 
from above d<>wnwurd and from before iMckwanK n lead 
plate, or a l,iin|ion of ioilofonn irauze haviiij? iRnni lirnl plueed 
behind the joint, to prevent injury of the retro-puhic lifixiies. 
Note thut the ttnbjwUr Htjanu'iiU na well n» the interarticular 



sYMPiiysr:oTo}rr 



cartilnpe. must lie ilivi'led, or the Ipoin^rJ will not f*e(>arato 
Kilisfiu'torilv. There m a idiiii, luvwfvtT (devisfri l>y Dr. 
Hurri.s uf riiirnj!.M)) in wliifli ihc >ub[iiilHC ti^rniiiciit is iiiteii- 
tionully \et\ uit'VUX : insiiead wf fuitin^^ it iu the luiihilc he 
eepurates iis central uml IjKltiiI altui-hnn-riU t4) the pubic urch 
(lO)3:flher with tJioi*e of lite |»eriiieul tatM-ia) with a blunl- 
^Kjiutwl bistoury, cloftoly " hujr^dnK " tli*^ Ixjne, under guid- 
ance t>f the Hnijer. Numerous advuntJifjes arc chiiTiied (or this 
niethiHl. 

The ymi havinjc: been divided, the wound is pai-ked with 
iodi*rorni ^^nuze and eovertd with a compresi* wet with 
bieliluride Hdntiuii, while the child is delivereiL either by 
lab<>r paiiiM ahme. .shijuld they l»e strong enoujrh ; or by 
forceps, if the head have already en^ai;ed in the [h Ivir brim ; 
or by versiiou, if it I*e yet ahure the lirini- The child liaviiig 
l>et^D delivered i^ handefi to an a.'^iHlaiit, or (raine^l nunte, 
who fhould have previously prepared Imwln of iiot ami eold 
water, etc., to .^wure its reanuseitjition, should thi.-* be refjuireil. 
The placenta is delivered bv exprension in the n^llal nmfiner. 
During delivery of the child, prei^fiure on the ]rochuntei-s 
must be made by Rj^lHtauli^ to prevent too wide aepiiratioa of 
pubie boiii-H. 

Opeu titefliof! of fifirrftfiitff irlfh hntj inriitHin. — An incision is 
made in the median line thn^ or four inches lonjr. bej^inning 
lialf an indi or an inch alMJve the upjwr etuJ of the symphysis, 
aud ending at tlje root of the clitoris, or a little on one *;ide of it. 

These tiwues are cut down to the joint, ami the incinion then 
continued tbron^di the cartibiire of the joint itself, the syni- 
phyHS beinj: thm* t*even>il from before backward and from 
above <lownward. Tlie pri'i-nulions to prevent acciilentnl 
injury of the urethra, bhuldtT. et<*., are the same lii^ when 
operatin;^ by the snbculiuieoufj method, by short incision. 

Delivery of child and placenta ac<-omplisbetl, the itMloforra 
gau2» tam|Kjn and sublinaite conipres^s are remove*!. The 
woun<l \» clcanacd with bichloride s<tlulion, liemorrhape 
Hrrested, and llie incision ch)sed l»y suturi***. It \a not ne<.*esiary 
to suture the boru- or cartilujjes. A catheter is us**d, as before, 
to keep ihe bladder, urethra, or vatrina from Itein^ nip}>ed 
and pinched U'twcen llu' two pnbie Iwuies while the latter are 
bein^ (*onl.inuou?ly held in apposilir>n by iL-sislants miikin^ 
preiMuro u^iou tlie trtK-hnDteriit while sutun^s ure l)eing [Hisseil. 




364 CUT7WG OPEBATIOSS OS THE MOTHES. 

The fluiurra — of silk or Bilkworm-priit — niny a<lvantiigeou8ly 
liasri through the fihnms tiHSuej* iM\ the anterior a«|»ect of Ih© 
]>uhic joint In very tht women a M'^Hirnte running catgut 
suture may 1>e usod to unite the re<Mi nnisoles, before the 
8ii|>ertiriHl otufl are put in. Aiitiseplie dresttio^ is appHeil lo 
the woiitid, un<l kept in place hy atlhHfive e^ri|)tt ; while over 
this is phired a strip of strong ruhher atlhesive plaster, three 
or lour inches wi<k% K**'"^ over the trochanters and nimpletely 
rounil the |H']viM, to keep the hoiie^ iniuiovnl4y in app4i>'ition. 
Ijiteral pnssiire hy the iLssi«tantji niunt l)e tinremillinjrly con- 
tinueU until immoliility of the U>nn* iH secnrefl Ky the roniplo- 
lion of the drewinj^s just der^criheil. Tlie ruhljer adhefflve 
plarter may he reinforeetl by additional ifupjwrl of an ordinary 
nniHJin bandage. All i*orts rif devirep — canvnit l)ell« with 
»trapH and burklei** EKUuireh bniit]n;;e« of H)lid rublter, a wire 
cuiratp. [nuMed platef>, S|>e«-i^d b^K Kund-bapt. etc. — have been 
UHetl to se<-ure in»iiiol»iIity of the lioneiJ. lint the strip of rubl)er 
plotter is always available, and it« eHieieut^ bati l>ecn demun- 
Blraie*! by numerous o|»erators. 

An antisepti<* alisnrlient |md, or a roniplrle '' <u'rhti*ion dretut- 
1/11/ *' (i*ee |>age 'J^JM) sboubl l>e uppliiMl to the vulva, and. as a 
further wcurity agniiiHt w}tsis, the vagina nmy receive a 
tainfon of twhiforni gau/e. or iuMead of tin.* an ounce of 
uutiseplic |M)wder (1 |«»rt io^lofirm to X of horic acid) may 
he de[XQ(ited in the vagina and leU there. 

The wonum mnsl remain ou her back for a wet»k, her lower 
lind s being stretched out straight and ihe knees lightly tie«l 
(ogethor. During second week she may turn on her side-. 
A tier three wi-i'ks she may git up. The |)elvie hnnda|rei<honld 
be worn for six wtn-ks. 

The dressing U]M>n the wound may remain untouched for 
6ve dayn, there l>eing no indicntiou of suppuration and do 
soiling from the lo^diia. The bowelH and hhulder must be 
nllended to as usual, a cjithetcr N'ing uh*i1 for the latter if 
re<piirt*d. The rest of the atler-lrenlment i*» the same as* that 
for ordimiry lalior cns<>s pfttA the abdominal wound, which ia 
ciireil for acconling to si)rgical rule. 

KHIK'ciid care should be taken lo ke*'p the external genitals 
and adjoining parts aseptir-ally clean, by washing them two or 
three linu*s daily with a mild bichloride Bolution, while a bed- 
|Nin is pliKvd under the nates. 



)jttL 




SYMPll YSKO TOM Y. 



365 



A third nietlioil of oiKratiii^', (Itfvi^c^l l»y Dr. E<!ward A. 
Avers, of New York, has beoii rc<vntly uradi^jcii witli sucrfsst, 
and prutui:^'f« well, lit roiitniHlistinuLiuii to the ^'Kubcutauu- 
0U8 " melh4xl, it might Ihs willed "suhiuucous," ibr no wound 
is made in the aknu It id n.M follows : 

Aytm^ Ope/ti^im. — The vulva, vfigiua, etc., haviujiC been 
made iiseptiailly olejin. tlie |mlient, on her bark, is Itrou^^bl 
to tile edj<e of the Iwd and ihe tbi^dis flexed. The Idailder 
and urethra are drawn to the lert by a urethral wiund, while 
clit4jris and labia minora ure ilrawu upward and to tiie letl. 
The operator's left index linger now enters vagina and piii;s<«* up 
ftlung potrterior groove of syniphynia until n^uclnrig the top of 
the joint, A finiull incit^ion. In-giiniing iialt' an tiirh below the 
clitoris, only long enough to adnnt ejisily the bbtde of a 
bistoury, is made over and down Ut the urtieulaliun. A blunt- 
pointed bistoury is then pu^^heil up ahuig the anterior face of 
the symphysiwt nitfier tb*^ vt-svielfl of the WitonB, until the 
jK)inl of the insttniment can be telt over the fop of the joint 
by the tip of the (iiigtr in lliu vagina, f luardnl by this 
finger, the blade of tlie bi^l^jury iw now worked down tltrough 
the artieulation. euttiiig from t«*t> Id iKiltoni. To sever the 
subpubie ligament the dirt^'iion of the bistoury mav i»e 
changed, so a» to cut from l)el«m- iipwanl. The Huger in the 
vagina easily deteniuned when the l»oue.s separate and the dis- 
tance between them. Delivery, ete., as in the other metho<i>t. 

The little wound is packed lightly with iodoform gau7« (to 
be removed in thirty-six liours) ; covere<l with a gauxe-drefis- 
ing (no suturing retiuire*!) ; wliile vagina and vulva are kept 
clean by bichloride irrigation. Catheteriam (the wound being 
above the meatus urinarius) luay be dune, it' oecMeary. with- 
out infection. 

Diffirultir^ dxirimj Operatiov- — Hemorrhage from the wound 
may be contntlle<l by ligature if [>o«*ibl<,^ — e«()e<'ially if 
arterial ; venous «M)7Jng. by a lamjMm of i^Kloform gauze slufl'c*! 
in the wound, with oouuter-preiis'ure liy the fingers in die 
vagina. 

There may be difficulty in finding the joint ; it i» n*)l always 
centrally placed, nor always straight By moving one lower 
limb of the woman while the o|)erator'H finger i.s in [Miniiion. 
the motion of one mde will thua reveal the situation of the 
eympln'sis. 



366 CUTTING OPERATIONS ON THE MOTHER 




In case the joint ho iiiichyloscd, a cbaiu saw may be paased 
tlown Ik^IiiikI ami uji in iVout oi'llie urticiilaliou, luul tliti juuo 
tion sawe<I in twain. 

Amdeiitiil inc-ition or hiceratiou of the urethra or hlathler 
should he sutured with fine tiilk. Ft' the wounds lUil to unite, 
a secondary ojxjration may ho iiei'tied ailer the puer|)eral period 
is over. 

The presentint? head of the eliild may he jammed so closely 
against th» puhic hones an to interfere with tlie 0|>eration. 
The preaentinir part should l>e pushed up out of the way, and, 
if space cannot tlien l»e ohtaineiJ for the lii^loiiry to cut from 
the back of tlie sympltysis forward, the iuct^iou must be made 
from before baeUward. 

Finally, he it reniembcriMl. lliat whatever the method of 
0[)eraliiijtr, rtvmjihyseotoruy is done for the most part \n the 
mten.«t of llie c/k'A/, and is designed, rhielly, to supphmt 
craniotomy uiid other methods of forcible delivery by which 
the life of the infant is jertpiirdized and sornetinii* lo-<t. 

The utility of conihiuintr KyiHphy:ie<>i4jniy with the induction 
of premaiuiv lalmr in rum's of contracted iK-lvis han not yet 
l>een |K)silively denioiislnited. 

In certain ca^'s, when the chifd i» dead^ symphyseotomy 
combine<l with enihrvolomy may be re«)rted to. in the lutereM 
of thf mttther. In practice these crts;^ have not yet been 
definitely -K'ttled. Thcoreticaily, wlien the ficlvis in fio much 
OMitractcil that the danger to the mother of a difficult craniot- 
omy alonr is so far reduce<i by sympliyseotomy that the reduc- 
tion ip jrreater than the additional rif-k incurre*! by the latter 
ojienition ; or, apain. should it be possible to oliviate the 
greater danjrcr of abdo[ninal section liy condmdnjr endiryot- 
oniy with symphyseotomy, the latter o(»eration woidd seem to 
be iudieated. These are matters for future decision. 



C.ICSARKAN Skitiom (formfrhj Gadro-hi9terotomtf ; later 
LnjHiro-hifgtnvtomjt ; more rerenfiy Orlio-hfj'tterotumfj ), — An 
operation which consists in cutting throut^h the walls of the 
alwlomen and uterus, and deliverintr the cliihl and placenta 
throu^'h the incision. The cases in which it is iterfornKMl are: 
{\) f-xtrcmr deformity of the pelvis, in which delivery by 
craniotomy is eitlier inijKJSsible. or woubj l*e more dauf^^erous 
to the mother than cutting into tlic uterus and aUiomeu; 




C^ISAREA^ SECTION 



367 



(2) cases of more raorlerate pelvic contrnHJon, in which crani- 
otomy 16 fWBsible, but <.V*iirean tH-rtioii ih rijL''it'o»l \i\k)u t*> ttave 
the life (jf the child; {'»^) iiiet'iiuiiiral ohslruolion in tbe [»elvi8 
frufii tihroid, ruiircrou:*, hoiiy. ur other tumors whirli rniuHil 
W puhhetl out of the way or siiiely removed ; (4) irrfducilile 
impailiori tit' i\ iiriinj child in ininsvtTHt! pn^*ntMliinifl ; {*')) m 
woriiL'U dyiti^ near tlie end iit* prej^miury, the cliikl, if wlive, 
is nipidly delivere<l hy |>fist-m(»rtet« Cu-siirenii liectioi* ; ((ij 
various other exeeptioiial eondilioiis restjltiiijr from intiiim- 
matory chaoses, c-ontttrictioiis, uterine displnoemeuls, etc., may. 
rarely» require the oj»eratiou ; (7) recently the ofieratiou has 
l>eea done in a few vnncss of eehuii|i**ia, wiiere more conserva- 
tive meiliodri of rapid delivery were iiupruetieahle. 

Before deeidiujLT ujHin a Ciesiirean operation it should he 
determined that the case is not suilaldc for delivery by syni- 
pliyseolomy. 

Pro4jmn*U and Danijrr, — Death nuiy result (1) from hewor- 
rhatje during or after tlie itiKTHlion ; I'l) fnnn Mhork, esperinlly 
in women greatly exhnueled ; i'i) from lifrittifiitinntid luctritlf; 
(4) from gejiticcnnitt. The |)ercenlajre of nnilernal recoveries, 
us dedutreti from slatiatit^ is notably uureliiil»le. The figures 
usually inehule alf chscs : alike those who die after the o {K-ra- 
tion, ami tho?e who die <iu arrottut of it. The result de|>euds 
more 0!i the eonditionrf pr(M*<Hliii{i, nUendin^, and foHowing 
the o|ierntioii, tlisiri u[K(n the ojrtration ilnelf. Not lonjr ago 
the rePuUs of wwiilled " ruitff-lwnt (\rmrean section" (caH:« 
in which pregnant women were torn open by the horns of 
infuriaiei] auimalsj were more favorable than catfce operated 
n|ir>n l>y surgeons, for the reason that the cattle were goring 
healthy women, wliile llie surgeon was operating on women 
exhausted by long hilior and with tissues injured l)y niisuc- 
ceasfnl attem]>t.s to deliver by for('e|)H. vers^ion, etc. While 
the mortality »W to he 50 jht tent, or more, it has of late 
l>een so far re<lured by improve*! methods and knowledge^ 
that by **a- recent analysis of ihe literalure of the world, 
conducted with the tden of determirnng the prognoeie of this 
operation under favorable *H>nditions, it was dis^'overefl that 
up to August, 1H88, thirty-nine Casarenn sections had been 
performed by thirty o|>eratorM," with the result that alf the 
luothers recovered iind thirty -eight chililren were saved ;' and 

) KdwarU Kv)UuLib: I'rftcUcal Miilwid-ry, iwge lifl. 




aG8 CUTTING OPERATIONS Oy THE MOTHER. 



thifl. even though most of the o|)erator8 were doing the opera- 
tion for the Hrwt linu*. 

Later i*liJtisti<'.s (1*S94) give the following results: "Of 
thirti:H;n niau.^ whurc the o[>erntion wju* |)eHormed hefore labor 
httil hegun, leii women ret-overeil and thirteen children were 
saved ; of six wteta^ whi-re the o|>eration wua [terforfninl at the 
bejjinuinj^ of labor. .«ix wonieu rwovered and mx rhildreu 
were snvt^^I ; of twelve <'ibH*.s where the women had l>een in 
labor t'roni two to six hoiint, ten re<*overed and eleven children 
were save*! ; of eighteen ca**es where the wuineu had been in 
lalmr from neven to twelve houns eight recovered and thirteen 
chiMren were suveil." ' 

The b'At TeM\\t& are obtuined by making the o|xi!ratiou a 
!HH.*alled " elfviivf " one— that it* to gavi ihe obstetrician (hav- 
iojr previnnsly nacertained tlie advi^y^biIity of the opt»ralion ) 
el^ct^^ a favorable time, place, etc., for its |terfornianee, instead 
of doing it bv conipulsitm under a4lverfie circuniHlaiicest, when 
other nu'thodfl of ileliverv have failed ; which simply mcanSr 
do it near the end uf pregnancy brfntx l*tb<tr bajihg ; elect the 
ti::ie and place ; secure n.ssistanii^ nurne^, inHtrnment^, dreasings, 
and prepare the patient by previoua treatment, etc. These 
thinjp* cnitHit* so well l>e done during the snihlen emergency of 
lalior, et^{>ecially at night 

Since burrouuding circiinuttanees and existing oonditious 
so far vary thai no two ^)\}A of caMi-a are exactly nlike, »tatia- 
tical results ninst vary also, and figures can therefore give only 
approximate iudieatioMA for future guidance. 

Unfavorable conditions, such a^ the atjiioapheric impuritiea 
of ho«*pitidt*; previ*»us exhaustion (l>oth of woman and woiub) 
from protrttotcd lalxir. or coexisting disea^ : previous injury 
from UDsuccesisful attempts to deliver by version, forceps, etc. ; 
bungling trom lack of skill during the ojveration ; negle<!t of 
antiM^ptir pre<antionfti ; and injudiciuujs after-treatmciu, have 
largely incrensed the death-rate. To be 8uc<*etwfnl, the o|teni' 
lion should not \m put otfas a last ret*orl, but jHjrtijrmed early, 
the conditiouH re<piiring it having l>eeu nia^le out, if practica- 
ble, at or liefure the l>eginuing of labor. 

O^n'rniion^ prrftaration for. — If practicable, let the indent 
avoid wdid fiHwl for twenty-four hours l»efore the o|jeratiou. 

t •^rniKlIn utiil .lurniAii : Ubst^trk Siirgi'ty utixiUiiK l>r. lt»lwrt I', llurrlai. 189^ 




J 



C^SAUEAy SECTION. 



369 



Empty iKiwela an*I MatMer. 8Lave Mie hy]>ofrastric repi*^*"* 
puliv.s, t'tc, StuI) ll»e alMlommi with nuap, water, ami Urush ; 
tlien wtitih it \^ith elhor. aial tlieu with u iniUl hit'hloritle solu- 
lion (1 to .{OOO), am) iloiirlie (he va^'itia Nvilli the hiitt-natued 
soluliuu. Tlie luwtT Itiiihtf to Uf wrap[i(nl in i^hawUtur blanket^ 
and the vUe^i Miailarly prutccleJ fVuiii culiL 

luAtrntnrnifi, t'tt'. — \ liistonry ; a st-alpol ; a ilinM'ti»r; a 
duzen hienutetutic i*orcfi» ; twelve new, clwiu, asH^plir ^jxiiiirfs 
(counted); !5|>ongf-hoIders- ; sris»>r8 ; iic('dle±4; nHdlf-holdcr ; 
coarse and Hm» aulineptic ^ilk for suturfti ; a solt-rutiber tuUe 
as larife as the litlk* (irijtter and two and u half feet tung ; two 
hy|to<K'rniic f-yrin^rif^, together with a timiilain fiyrlnge, it.Hit>- 
forni i^aiize, anlisi^ptic eottuu, Hanin.'! handuL'e for alidoiiieu, 
anil everything' nt'<v,sc*ary for the Ufual antLseptie dresMiups. 
Since the womb iu bad t-jweu of delay may be found j*o far iu- 
jnred ai* to ritnder a PornvMuller o[K»raiion adviriahle, the 
additional in^^trunients ueeesjury for this pRK'edure should 
also l>e ready, viz. ; a Paqueliu cautery, a ix*<iicle coiupreseor 
(KtH.'l>erle*s, Tail's, or tlie tterrc-turud of Ciulrat), aud two 
long, thick needles for tran^iixin^ the slump. 

ISrandy, ether, erjrot, dij^italis, niorphia, strj'ehnia, aud 
plenty of hot and eohi water, toijether with a »'paratt? table, 
provided will) appurtenanees for renuseitaring the child, should 
be in readiness. 

AAjtiMmiU. — First, the chief as*if»tant to help the operator; 
se^'ond, one for the arua^hesia ; third, one Ut take care of the 
ehihl ; fourth, one to hand instrumenli* ; and a fifth rt-ady for 
anything (he 0|M'nU4ir may desire. The a.^y'i.stants should 
receive s|>e<'itic iuHtructions, Jtefore the operation, as to what 
they are to do. 

t)wing to the gr^ai danjier of prolonged delay in ohlaiuing 
iu!*lrnment.s ius?it»tuntH, aiitLsepticft, etc. (as may iK-cur in coun- 
try practice), it may well l>e quei^tioned whether it would not 
lie iH'tter to do the ojKTaliou witli a knife, neeiUcs, and .«utures, 
UHin;: boiled water for aiitisepti4' clennliness, and havin;^ "(»ne 
phyMcian and a few women " tor a-ssiHtant**, rather than WB«t6 
venj much lime wnitiug for I>etler appliances. 

Ofwrution, — The oi>enit4)r titandn on the right side of the 
patient, who should re.«t on a hiph, firm table, with her shoul- 
ders aliL^iilly elevated anil tlie lower lindw* nimlerately Hexed. 
The chiif ai^^iit^tant, staudiug ou the leiluud fiu-iug the patieut's 

34 




370 cuTTisa OPERA rroys on the mother 



feet» steadies the uterut' in the furdiiin line and |fryiluc^a mod- 
erate tension nt* llie alidoniihal wnll over it, by preaigiug the 
ulnar Iwrder of emh hand down un the ?idtt* ot" rlic uterus 
while his thumbs rcftit on the t'undns. Tlu- inciMon is then 
made in llie nivdiiiii line. Tlie (finjtU ui" tliii* iini/mn drpcnds 
tHion the Tiiftbtiil »4' i>pt'nttin;r seK-cti-d. Tfiere ine really ttvo 
methods: one with a H}uifi ntHlinniital ineisifti) i>f" ftmr or five 
im'hf.s duriu>< whieh the oiH^ralor \\\\\ take (Mit thfchihl wlille 
the wond) iftuniiut hi ihr afxlotniuitl caiiiy ; niid auothrr with 
a iomj alKloiniiial ineiMon cd' seven oreij^ht inclies, in which the 
uueut utertiH i» brought ottftritlf of the abdominal wall before it 
itj iueirted and the c-hihl extraeted. 

Both o|)eratiotis will nnw l>e dt-serihird. 

1, Ojif'ratioti with Shorf InrUiutt. — The ineision begins one 
inch below the uiidnlieus and v\\\.W one and a half inches 
alvove the pulK's. The tissues are divided, Inyer by layer, 
uiilil the jteritoneuni be renehcil, tlirtmLrh whirh the womb 
mav be faintly hct-ti. Illoedinj; vi?Nst'l.s iimy be twisted or 
li^attnl bt'fore o|H*ning jx'ritimenni. I'ick np this ntendirane 
with artery foreepe, Di*'k it, intmduce t^ruifved ilirertor, and 
slit it up with bintonry llie refpiired length (wmie openitors 
prefer to make tirfil a vrnj hhort ini'i(*ion, d^wii to an<l tliroii^'h 
the j)oritoneuin, then pii»* in the finder for a jL'uide. mid pro- 
haii; the ent with stmnp wlsfHtrn). Nest eonieH the uterine 
innjtion. Before this is done, the Inoj* t^f rubber tnbin>r is 
puphed up, then over the top, and diuvn Iwhind the fitiiiUiB 
uteri until it is bmuphl around the Inwer Hirment of the 
womb, ittf two ends are pivei» to an a^nistant wlio eroK*pfi them 
outre (without a double knot), and make»4 Kane triir'tion, thus 
preveutiujr hemorrhage and keepinjr the womb Hteadily pressed 
a^^iiutft the pultea. Anotlier asr^istant keejw the abdominal 
walls in close contact with the uterus to prevent extrusion of 
inte^itine and entrance of litpnir anniii, ct4'., into llie |»eri- 
tttneal cavity. The uterine incision Ls made in tltc median 
line with a s<'aljM'l, l>e^Mnninp below, and lonp enou^di to adndt 
a tinjrer, which is intnulueed, and the cut prolonged o])Wftnl. 
with st;i?«ors, to the extent of four or fiv*^ inch**s. If tlie pla- 
centa Ih' inserted juKt under the ineinion, never mind that ; 
cut on tlirough an if it were not there. (Formerly it waa 
adviscxi to (Mit on one si<le of the placenta, or to sepurale the 
|>art overlapping the incision ; this is not necessary, and it 



I 



CESAREAN SECl'IOX, 



371 



wastes time.) The han<i now seizes timt part of the rhihl near 
the incision — hemi, hrecrh, or leel — iimi extruft.>i it rii|iidly, 
the aj«i!«lant nieunwhilti iiiiikiti;ijr nut^iili* |ir4>s»urr tn |>ruiiml« 
uterine nmlnit'tion. Tlie roni is r];itn|)e<l imhI ciiI, and the 
chiUl handed iivrr to an nst*ihtant. Tlie iiterur*, riuw reduced 
in sizi*. i,s j^mdually passed out throujrh the uhdoniinnl iuei- 
sion. (Fonnerly this wjls md done, Itiil ih^^ iiperaiion was 
complete<i while the woiuh leniuined inside the alnhmien. ) The 
womb in now gnia|)o<l hy the two haod-s and the phureuta de- 
livered l»y expreswinjtr it uut thniuirh tiie ineij*ion. ShouM this 
method twt nnrret'd (U once^ the hand L* pasi«e<i into tlie incinion 
and the phieenta earefnlly [RvleiJ oH* and exlnieliHl. The 
membranes :*honhl l>e twi^ftetl oul and a finger (Kiiwed from the 
uterine cavity thronjrh the internal os to iiwnre ita I»ein^ un- 
obslrueleii for future diwharpes*. The ut*»rus is next irri}j:ated 
with hot water or a hot mihi { 1 to oOOO) solution of hicldoride 
of mercury. Diirin;; all thew prtHeedii»|^ hemorrhage has 
been prevented by the rubber tubing held by the nfisist^int, 
and which will be continued until the uterine wound has i>eea 
sutured. (Some operators prefer U) control liej]i')rrha;re by 
havin»;j an art.-iit'tant irntsp the lower s<'^Tneril of the; uterus 
with his /nr/zf/.-*. The ruliber lul>e must not be held Ha ti^^htly 
to injure the tJA^uej?, nor uiuat it be continued wi* loiij; im to 
nwe |»araly.sis and inertia of the uterine witll with ctinsequent 
hemorrhajfe; and further it should lie renienibere^l that if the 
tul>e l>e tightened Ix-fure the child is extractetl, asphyxia of the 
infant will oetmr unlefls* it be extracted quickly ; heuce the 
0|ierat^>r, though secure a^^ainst fear of bleeding from the incia- 
iou, mutit not dawdle with the remainder of the o|)eralion, 
but use all prudent ex|>etlilion in ha«tening its completion. 
The Ion«rer the |)eritoneum Is exix>se<l to the air, the f^reater 
the rii»k of nulwcMpient |>eritonitis. ) liefore suturing the uter- 
ine inei.sion, a tein[)(irary tamjx)n of iotJoform ;:auze is placed 
in the uterine cjiviiy, li> Ik* witlulrawn U-fore the t^uture;* are 
tietl, and a 3(M_^>nd jj^auze tamiwrn ititrcMlncwl with one end of it 
projectiii»^ ihnjuifh the cervix into the viurinu, throujjh which 
it can be withdrawn a day or twu after the operation. (In- 
Bteiid of the lani|)on, some operiitors ilry the uterine i^vity 
and duKt it with itKloforni.) The mrthrni of mitiiring i\\(? uterus 
irt nuifif ini|K>rtanL Fii'ttt : tleep sutures of larj;e-8ize«l silk, 
from oue-half to two-thirds of au inch ajiart, the ueedie to 




CUTTiya OPERATIONS ON THE MOTIIEFL 



eoter half ad iueh from the edge of the incisiun, penetrate 
down to but uut tbruugli (he mucuus lueiiiltraue, uid cuiiie out 
half an inrh from tiiu opuosius edgt of the indfiou. (See 
Fig. 1H8.J Frunj eijjht to twelve of thetfc deep sutures may 
be required, luifamd .- gu/Mrjicinf Jtidntrji (of fintr ailk or ciit- 
gut) out ijuarter of uu iufh»|)arL, which will juiHs o/j/y through 
the i)eriloneuui, hence railed "^^ nrro-Krous.'' The cut borders 
of the i)eriioueuni may 1m? stret<*hed ami turiie*! iu Itefore tlie 
dv*»p liulures are tiwi. Ti> facilitate this turning Lu, a little 
(itrip of the atilrrior l»order of the muscular wall may be cut 
away, leaving un overlappiug ledge of perituueum to turn in ; 

r». in. 




Bhowloff potltlan of nuturei In relmlon to structures In uterine vail. (After 

liALARIN.) 

0. Peritoneum: b, uterine muscle: c, deriflua; rl, supcrflcial luturc : t. deep 

■Qturai. 



but tliis takes lime: Htretcliing is usually Huffieient. (See 
Fig. 1A9. ) InKteat] of thiA turnittg-in device, the Lembert 
method of Huturing may Ih> m<ed. 

When suturiiig i* complete (not l)efore) the constricting 
rublter tul>e is removed : ami any hleciliiig points iu the 
uterine iucittitm ."^Imuld rpccive additiutml suturet*. The womb 
h then dcaiiried aud roturne<l to the alHlnniiiiul cavity, and 
the o|)eratiou in completeil by nuturiug the tilKlumiual iu- 

CLHOU. 

2. Ojieraiiou vith hmg InHjtioth — The iucipioii exteods 
from a |Kiint one aud a half inches nUtve the {>ul>e8 to two 
inches al>ove the umbilicus: iLs up|>er end gocB obliijuely 



C\ESARi':A^ SECTION. 



373 



Dround, or to ihe ifide of (not ihromjh ), the uniliitious. It ia 
mjtile in the a^iiiu niuiiiitir ixs, the " hhurl iiuit-iou '* jutft de- 
Bcnbwl. The object af llie long iii(>tc<ioii iff to iniike iin 0]>eD- 
iiig- large ciioufrb to allow the iinwoumled womb with its un- 
d'«turl>e<J ooDieot* to enier|iu ihroiijrh it, which liist it; juroni- 
plinhed hy piiKhiii^ the wonih tip into tin* inrisioii while the 
BlMloniiiml walU are prw^eil hark over rl ; when ditKeult. tlie 
proeciMliii^' muv he t'ueilitnttM] liy niaiii|>iilutin^ the uteniM w) 
BB to j^et oue Ki'ff' of it lo pdJlrudi" lii>l. Take uotiee, tliiit, 
owing to the h)ng exlennion of tiie ulHlonuiiul incision, the 
inteetiue will be exposed, or proirude at the upper part of 

PHi. 189. 




Showing the mitiircs wtirn tli-d; pfTiiMUcnl unrfurfK Itrinii lintu^:lil intu contact 

Ity Lhe Bti]>4>rll(-litl suturos. {AfliT (IaI.arin.) 
a, rerltuiifum ; 6, uti'iioc muscle ; e, dccidua ; d. fcupcrflelal duturcs : e, deep 

suturf. 



the wound, after the uterus is broufrlit ontt*ide ; therefore, to 
aw/If/ thin, long HUtures (five or six of tlieni) are /kj^W'^/ through 
the. upj»er on»i of the in(n»*ion bffore the uterus is disturhcnj, 
and remain hx>He and relaxe<l, until the uterus is extruded, 
when thev are imnu'diately lightene<|, and thus the U|i|>er end 
of the ineir'inti is quirkly closed and tlie intestine kept liack 
during the renininder nf the o[>eration. 

The oaii^tricting rtihher tul>e it* now pa;^Hl over and down 
behind the fundus, until it cnd>ra<"e the lower segment of the 
wondt. when it is lightened by the iiNHSiant as just previously 
deserihed in the o[»enUioii with short incision. The other 
■tepB of the ojierntitin — incising the uterus, extracting child 



374 CUTTISQ QPERATIOSS ON THE MOTIlEn. 

and plncenta, suturing the uterine anti alwlmninal wounds — 
are essentially iho .same n.^ wIk^o llic ?liorl iiuii^ion is done. 

After eitliLT methuil of openuiu;: the idwltmiinal wound is 
drespe-^l antise|iti('«lly and a dose of crjjot (or erj^otine) given 
to inainUiiu uterine foiitraction and prevent hemorrhage. 

Aflcr-trcaimint. — The jwitient should remain on her huek 
two or tliree days, the abdumiiud wiill \m\\)x, well sup|w)rted 
with a binder, and the vulva dressed an!is(']>ti«*:tlly :in in 
ordiuarv lal>or eafies. To iivoid rmutfiurf i whictn is sometimes 
a troul)lei>ome syrnploin) no fowi shouM l»e taken fur twelve 
flours or even twenty-f<nir, iiivd then at first only li<(nids, milk, 
heet-ten, ete., in te4W|H>iuil'id or lahh>|KHjnful r|u«ntities h« the 
stoiimi'h will tolerate, and repeati'd at inierviils of an hour, 
t^mall p]eee>) of iee may he Hwalluwe<l, wliieh euntrihutes also 
to relieve thii^t. If vomiting jiersist, e\i|»[x>rt the patient 
with nutrient enemata and stop all rnoutli-ftH'din;^. The 
Ivowels (having l>een well oinplieil iH^fore the n|K»ratiou) may 
remain undisturlaMl forty-ei^lit hours, when, if not acting 
spontjineously, a soap and water enema may he given, or a 
glyoerine siip|)0.'*itory. ShituM lympaniteH ocenr. a 1easiK)on* 
ful of tur()entine nmy he added to the enema. The hlathler 
must hn emptied hy :^terilize<l ealheter every eight hours, if 
required. It' I fie ntenw were packed with pntize during the 
operation, the tamixju must be removed after twenty-four 
hours, aud a seeond one put im if desirable, on Hecount of 
bleeding. The suture*? in the abdominal woiitid should remniu 
ten days. The child shoidd h*i [lut to the breast Jind the 
woman have the same Irt'atmenL ns afltr an unlinury hitwjr. 
If all go w(dl the patient may nit up in \m^\ after two weeksi 
and sit up itt a ehair after three. 

pRiTrtt^H's Traxhverse Funi>al Inpibion. — In this method 
of doing a Ca«arian section, instead of making a longitudinal 
ineiBioa in tiie median line of the anterior wall of the uterus, 
the incision goes transversely across the lop of the fundus, 
from one Fallopiiin tube to the i»ther. or \'m\n one round liga- 
meul to the other. The advantages claina^l for Ibis jtrnreeii- 
ing are : 1st, In consetpience of the abdominal wound being 
higher, there is Ie>s danger of sul)se4ueiit hernia through the 
line of the aivlominal incision. 2iid. Dimiuishfd hemorrhage 
ixom the uterine incision aud u more firm and nipi<l shrinking 




ponnas operation. 



375 



of the uterine wuuiul. 3rd. After retraction of the emptied 
uterus, the uterine wull at the fuiulus \a thicker thau it ia 
luwer down, and lliert^fort' {idniits of more firm cUmure by 
riutiires ; aud, «iflor suturing, miiKsit^e of the uteruf? — nhauld 
this l)ft required in promote eontractioii — t'an l>e ?iiore fearletwly 
employed than when the incision has Ix'en imule in the anterior 

Willi. ' 

A moditiiation of Fril.HchV method lui,^ \w\^x\ reeeiilly priic- 
lised hy mukinjir the t'uiidal imision /omjitudhinf in^fteurt of 
traiiitverse. The ineisioii, nix or seven ini.'he^ m lentrlh from 
be':inning to end, comnifiKes on the iHwterior asijet^'t of the 
fundus and exteuds ulon^r the rneiliaii liue over the top mid a 
little way ilown the anterior surface. 

All these methods, iiiuler favoraUle ('ircumstam-es have given 
good results. Ex|H*rieiK-e lias not yet dernonstrnted which is 
the l)eBL Of one thing, however, we may lie snre, vi/- : iu no 
iuHtjinee slundd the uterine iuci;?ion l)e w> low lu* to cut into 
the thinned se^^ment of the womb Ik'Iow the retniction ring of 
Biiudi. (See Chapter XXVII.) Thiii iliinned segment cannot 
besij firmly secured hy suture*^ a-s thethii^ker parts of the uterine 
wall higher up. With regard to hemorrhage tliere ia uo more 
danger from the Iniigitudiiuil incision, provided it l>e made 
exfxctltf in the sagittal line, than there is from the central trans- 
verse cut- With ]»royjer control hv tlie rnhlier-tulie touniiqueti 
the ihuiger r>t' liernorrhage is small, no matter what incision Ik* 
choeeiL. 



Pokro'h Operation (/orm<T/?/"Gastro-hysterectomy'' and 
" Iji]mro-hy.«terectomv," also *■ Ovnn>diysiereetoniy," now 
"C'oilio-hystere^'toniy " ). — It is C'icsarean section with exci- 
sion of the wond), ovaries*, and Fallopian tubes. In Torro's 
original ojK'ration the uterus \\w» incistMl and tlie chihl ex- 
tractetl while the womb mtutitteuf !n fitr aMumvu, the organ 
waH th'ft brought out through the aliiloniinal itu'ision and 
amputated, :u* di-seriU'tl iielow. In MuJler*s n>i><U(ica(ir>n of 
Porro^a ofKTatiiai the uterus is brought out of the long nl> 
domiiULl incision bt-fon: being cut. lus just described tmJer 
Ca-sarcan Section. The cimdiineil methods conslitute the 
** Porro-Multfr Opmitfoft." 

The prejmralions for the oiveraliun tire the same aa already 
deiK:nbe4l for Cu^mireau action. 



37G CUTTlSa Ol'ERATIOSS Oy THE MOTHER. 



The cajtfn in whii-li it is iMTfoniu'd nrt^ \\» follows : 1. Odeo- 
mahria: a[>art (Voni tlie ftelvic deformity rw*ulniig troin ihb 
diseiu^, whirh luny rcM^niire iili«loiiniiaI section, the rcMnoval uf 
tlif ovurittt and uttrrus arrf^fj* the (lintmff of the Itontit, wWwh ii 
C'iPsarenti r^rtion does not 2. Cases of (^'a-siirean H'<'tion in 
wiiieli there ii* rompfrte ■intriia ttf tttr uirvuK^ the orjiran failing 
to retniei, ami ihiifs endangerinjj deiith froiii hemorrhage. 
3. Morh'ti ijrotrthif of the uterus (fihroid or iihro-iuyonnitous 
tunion«) eoexi-^lini; wiih prej^^naiKV. 4. Wlien ihe uterine 
cavity is in a eouditioii of septie infection, or when the walls 
of the organ have lieen so far injured or inHanteil ns to render 
it Nifer to remove than I*) leave it, 5. In en.se« of complete 
ru[»ture uf the uteruj* and ewafie of ihe child into (lie flNlo- 
men. 6. In eieatri^ial narrowing of imrturit'Ut ( anal whieh 
would ohiitruet hndiial dit^'harge. 7. It ha.s luen advised as 
Keing easier to an unskilled surgeon than the earefui suturing 
of the womh recjuired in (-amrean Kectionf?). X. In any ex- 
treme «»j*es of |>elvie ohctruetion (whether from osteomalacift 
or other cauHv) the Forro o[)eralion may he done instead of 
(.'avareau section, wheu it ie desired to uuh^x the woman and 
thus prfit'iit a future pretftiamy, 

Ojtrftih'nu. — The j»ro<'<HMling is jiraetinilly tlie Hanie ns Inv 
fttre dewrilte<l for Cusyirenn Hellion (which we), as fur as ex- 
trariiouf* of the child and ]ihicenla. There are tuo chief meth- 
(xls of doing the r«*t of (he operation (and .several niudifieation« 
of ihem). de|»eiidiiig niaiidy ii[t(»u the management of iheptumiJ 
or |H'<liele from which the womh Inu* l>een cut oH'. Thcne two 
methods are: 1. />/rn-peritoneal ; '2, //*/r(i-|jeiitoneal. The 
pWm-|)enloneiil oi»eration i.« the more Mni|de. eahV, aiid eapalde 
of rapid exeeution hy an inexi*'rt ojierator; the intrft-[>cr\to- 
neal niethml iH tetlious and riH)uiretf a H|»ecial i?kill to c;irry it 
<»ul suci-ewfully. 

Kvttft-prnUiuml Operatimu — The ehiM and plneenta having 
l>een exlra<'te*l as in Cai^nrean section, the wire lix>p of h 
Tail's, Cintrat's, or Kixdwrlt'*'."* ciinxtrictor is plaee<l round the 
uteriw helow the rnl>lter tuhiiig (eare heiiig taken t" avoid 
including any part of llie hladder or intestine), and tiglilened 
until circulation through the uterus is arresteil. Then two 
ihiek, long ne*Hllt« (ordinary kuitting-needleH will do) are 
|m>»H'd through the eervix at ricrht angle** to each other, Ac/lr/i/f 
the wire, which gerve, after amputation, to 5U]ijK.»rt the stump 



POJiRO'S OPERATION. 



377 



and keep it ouhhie tho iii«loniinHl iiiclsinn. (Henco the torm 
"extru-periloiieul." ) Tlie ruUlier tiil>i»i^ is now reiiioveiJ, and 
the womb ani|)iitaie<i ahout llirft-quari**rs of an inth alxtve 
the needles. The Htunip is [riiiiiiied down Id biiU' iiu inch 
from the wire; seared with « Piuiuelin cnukTV, or brusheil 
over with a st)iiition nf t*lv|*tii' iron lo Mlii|» l)kH^lin^. Sul»*t*- 
qiient heniorrhu^^t' may Ik* arrested l»y ti^'-hu-nin;^ tlic toii- 
slrifior wirt'. wiih u riirn nf iis screw, (hif* inslrunifut rftnuin- 
ing in po-sitiun lUter iLh u[K'rntiou. The ^tunip ir^ nfnv tk^-teuetl 
l»V sutures rtt the lower end ot' liie aluloniina] itieisinn and the 
jwritmicum stitehed to it on nil jmriisui' ii^rirrunit'tTence. The 
peritoneal cavity ij* then wswhed out, and the ahdoininai iiiei- 
sion I'itieHitl by suLureK in the asual luMuiier. The c.\|M>se<l cud 
of the gtump is <hi«twl with irKlotbrni and dreN*iMl antisepti- 
cally with the reiJt of the wound. The dressin<rs should l>e 
reuewetl as often i\a they lK*n>uiG wjiled by lt*«ktiL''e frum the 
8tuni]», the fonstrii'teil portitrti of wbieh will come away, leav- 
inj? a jrriinnlatiuir Hurfuee, in ten or twelve duyn. 

Iiifi'ti-fitrifotn.ii/ Ojprrtitioti. — In this o|K'ralion the cervical 
£>ttimp instead of brin^ e?c{H)s<i] at the abdominal incision, is 
dropped int(> the [H.'rit(MU'al i-avity (hence the term "intra-|>eri- 
toncJil,") or the siuni]» iturff in removed after amputating: the 
woad), no that the entire uttruK (^cervix aa well lu* ImmIv) ih 
taken out. When the slump is U'l^ in at^er amputation, it is 
ditfinfei'leii. its bI(H**lin*r v«'?«y'lH li,L'iited. and itr* wouinhM] sur- 
fueeti drawn to;retbcr by sutures, alter whidi it is drojipe*! 
back into the abdominal cavity. When the stump itwlf 19 
taken out (a much more ihlticult and tedious pr(Kve<liii^J, the 
uti'rine and ovarian arteries, on em-h side, are tied, the broad 
lijuramenLs secured on earli side by stron^r silk ii*ratnrcs, the 
atlachment of the bladiler to the anterior surfa<^ of the lower 
uterine se^^ient i« severed by incising the j)erit«ueum trauH- 
versidy and jH^lini;: off the connwtion with the Hntrer; all 
otlier attachments of the cervix to the vapina arc cut through, 
and the stump renioved. Any bleedin;; (Htintjit are lij^atiHt, 
the Ii<ratun*s beiufir \et\ lou^ enough to juiss lUiwn throu^di the 
oponinc into tlie va^jina ; this oiKMunj: Iwnu^; afterward clwed 
by Htitehin^ the jwritoncal covering of the Idadder (in front) 
to the peritouenl layer facing: Diuiplas's ruf-ftcmr (l)ehiuil), 
with a coutiuuouH caty:ut suture. The up|»er part of the 
vapna ia packed with iodoform gauw.'. The toilet of the ixiri- 



378 VVTTJyu OPKHATIOh'S ON TUE MOTiiFM. 

toneal ravity. t!ie cWure and rlrewiiip tif the ali<loniiual wound, 
etc, is done fi.s usunl. 

Still anoilier nicihoil <H" n]H*raini_f in in completely im^eri the 
iiteruj* (aH**r lukiiij^ uul dtild and [ilufcnla \\\ the (V-mirean 
section), sjj that it i.s turned iiwitlo uuT uiid piilltd through 
the vagina bo that th« ft*rvix is at the vulva, where the umpu- 
tatitMi and suturing;, ur complete excision of the slump, may he 
ncroniplishcd. 

In casfs wliere the cavity of iht- uterus is the .stiU (if »*e|)tic 
infi^rliau, ^rcat care is ueeeHsary lo prevfut any so[)lic fluids 
eutvriug the [lerilone^il cavity. For this pur|H>!*e a lar^re :>he«t 
of thhi rul)ht*r |surh a^* i.-* Ui*t*d hy deutinis) is perforatetl with 
an oivcuiu;^ suthciently larjje to jmiss over the i'lnuitiH and duwu 
until it vucirch' the cervix ahove tho ooiistrictiuj^ tube; it 
rlrwcly cnihraecw the ulcrut*. and Huids run over it, inHtt«d of 
entering the uIkIoukmu In ca-s* the rulther (sheet l>e not uttain- 
able, tile nhdoniiual wall \\\i\s he held hy the nj«istaut as 
cluHely aw |M»**4ihh' tu the .siden of the uterus, or, in addition, 
moist antiseptic towelrt. jireviously wruny out, may he |>aeked 
on eaeh side of the uterus to alworh any overilowiu^ fluids. 

The after-treatment in Torrti's o|jeratiou L* the same as for 
Cawirean section. 

CiELlOTOMY (JjafHirnhmiii, Cantrotomjf) simply means cutting 
thpiiujrh the nhtlominnt wall cithf and removing the child, the 
latter having ah-eady «v<aped from the uterus, wholly or in 
part, ihntugh a rent, ennstimting a rupture of the organ. 
rlat'enta, niemhranes, and hhM*iU-l(»t> are rt-nioved through the 
wound. The lorn e^th^res of ihc uterine wound are unite*! hy 
antist^ptic silk sutures, nnd the case nnuiaged like one of 
Gcsarean seetion. In ease the suturing fail to arrest hemor- 
rhage, the wondi nuiy lie eonstricted and amputattnl above the 
cervix hy the Porro operation. Ljiparototny is nls(» performed 
in cases of extni-uterine pregnancy, a« stated in the chapter on 
that subject. (See Chapter XL) 

C'tEiAO-ELYTROTOMY { Ija/Hirrheliffrot07mf, Qaittro^ltftroUtmy), 
— The ehief jmrpise of this oiwration is lo <Ieliver through 
an alMhuninal incision irithout ojnniufj tht* peritoutnl tnviiii or 
inci/rintj (he uUrim troll. The woman is placed as for Ca'sarenn 
section. Five afiaistants are requirwl, one on each idde of 



CfELIO-ELYTKOTOMY, 



379 



and two fucinrr tho o|wralor, wbo stamls on list' rijrht of Iu8 
|iatit*ut; aiuillitT givt^a fther. Tiif (w uti^ri shouM iiuvf l)iH?u 
previouHly ilihile<l. nalurally or nrtiHtially, ainl the bowels 
emptied. One asiirttant f taring the HurpMui's letl) drawi* the 
iitiTUs upward and to the left, thuc Htretchiu^ the [*kin in the 
rij^dit iluK^ re<riou, when* tho iiicisidn is made, niu* ineli ahove 
and [iflrailfl with Poupnrt'H lii/mnent. txtenJin^^ fmni a junnt 
\{ itirlK-^ aln»V4' niid to tht' outside u\' rhe H|unt' of" itie jailicsi, 
to an iiirli ahove the anterior r^n|>erioi' ^sjMiie id' l]je ilititii. Tlie 
ahdoniinal nittsclt*!* are cut, htyer hy layer, and the ras<ift 
Iranr^verKaliri liooked up and earefully ineised on a Key's 
hernia direelor, to avoid wounding the ijeritoneuin. Branches 
of su{)erH<-ial epignHlric artery may rerjuire holdiiip-forpeps. 
With the tinper-ends the jwritoneuni is eoretidly separated 
iVnni the Iransvernalis and iliac f'aseiie until tho vapiiud wall is 
readied. The aHi-iti(asjl at the ojHTatorV lell (luhls I ark jieri- 
toneunt and inlnstine with a iine, wtinn niii»kin ; anolht-r one 
draws the IkmIv of the uterus u])ward and lo (lie leH, in order 
to ex|K»*e vaginal wall ttn ihe ri^lit ^iide ; u third inlrodnres 
female catheter into bladder, liohliit^ it "in llie known direc- 
tion uf the lM>unifary line between tiie bladiler and vajrina,*' 
below the ureter, ort the side where the operation is being 
perfonned. A hhinl \viM*den or ivory r(Hh resembling obtu- 
rat<»r of eylimlrieal .s|H*enlnm. is pas**ed into vulva and vagina, 
bv which the vaginal wall is litietl and nuidc 1o jiroirnde at 
the yile ni' the incisiiiit. With a iberiiio-eaulery or galvano- 
can8lic knife (the surrounding parts being protected by wet 
eonipresw^). the vagitijil wall ir- cut over the projecting ruti, 
parallel \\\*A\ ihe ilio-[nctineal line, and an far below the uterus 
i\» prai'ticable. to a\oid injuring if/rtrr, Douglas's sac, and 
uterine arteries. The short ineinion thus made is extende<l hy 
imriug with the index-finger ends tnwani the f^acral prom- 
ontory and pnbic (lymphysis. avoiding, in the latter direction, 
injurv to blnelder and urethra. The ealbeter is tlien with- 
driiwn, the niendtraiies (if ((till inlitct) rnptorctl, the fundus 
uteri tilled to the op|)oiiite side, iiiul the os dniun l»y a finger 
toward the wound, through whieli tlie ehihl is then extraetwl 
or delivered by titreeps or verMon, a.** the prej*entation may 
rrtpiire. The plfitenia is delivere<l by "expression" through 
the incision. The wound is eleaisi-etl by earbolizeil wann 
water — some of which must l»e injeele<l per vaginam — and 



380 MVTILATISO OPERATIONS UPON THE CHILD. 



the edges of the uhduiuiuHl incision are unital by interrupted 

sutures, and the alMlomen covered with uutiseplic dressing. 
Tlie lila<Ider i*hoiil<! I»e tested for rti*tula' hy injecting warm 
milk. If uny are (ii^covered they should l>e !*t'we<i up with 
catji;ul lijjiHureM, which iiiuy remiiin. A speculum, placed in 
the wound, may he nece*^iry to 8e<Mire hleoJing ves^^ls during 
the operation, and, failing in thi^ the vagina as well as the 
womb may be l4iinpc.»ned with pledgets of i(Kloform gauze. 
Thii* operaiiori it* very dithcuU and rei|uirefi MH>re than 
onliniiry ^kill. It ip now si^Kloin |»erfortiied, and, since by 
improved tiictluHlt* of modern praelicc, opening the peritoneum 
i» no longer the ihiiigeroiis proceeding it usetl to be, there 
would seem to he little nece»dty lor 00 complicated and dan- 
gerous an ojferation. 



4 
4 



CHAPTER XXI. 



MUTI LATINO OPERATIONS UPON THE CHIUX 

The object of these operations ih to re*luoe the size of the 
child, or divide it in ])ie<*es, s<> that dt-livcrv — otherwi>=e im- 
prarticrthle — may hi? accompti^hfd. U|X'raiiiig n|K>n (he head 
is called "craniotomy" u|>on the btnlif "embryotomy." Since 
the term "embryotomy" literally meaiin rutting the embryo, 
it is Aometimep loottely uwed synonymously with '*cntniotomy." 

The eondilioniii r(H]uiring niutilution are chiet^v malpro]X)r- 
lion betwctMi the size of the chiM and fK-lvit'. ur <itlirr mechan- 
ical obstacles to delivery, such a-s impacte<l sliaulder prestenta^ 
lion ; arrest of mechaniHm alter iJOf^terior mtntiim of chin, in 
face caww ; Im-ke^l twiu», etc. Wfien the child is deail, and 
delay in delivery endangers the mother's life» rraniot^miy may 
b« done to expe<tite a lal>or that might in time end without 
artiticial aid. 

When the child is a/itr, and .<incrificing it is nec^^vary to 
save the mother's life, the choice Itetween craniotomy and 
alHlominal •i^'lion l>e<'omes a serious and dithcult res|toiuu- 
bility. As a ride, muet obstelriciiuis accord superior value to 
the mother's life. In some cases the necessity of a mutilating 



MUTILATING OPERATIOXS UPON THE CHILD. 381 

operation upon the <hiliJ, ns well as alxiomiiml eeolion upon 
the mtdher. may l>e oliviah'H hy syfii])hysetiloniy, a.s alreiuly 
explained. Much will ile|Hr)(l ii|h)ii t\n* rondifion of mother 
and rhiltJ, ami ilu- rliam*-?* of iheir survival after an alulemi- 
innl o[>erutiou, wliifh will n;:fiiu lU'fK'ntl u|mju the siiririta! skill 
of ihe operator, ami hi:^ assi^taiiU^ ami the favorahle or un- 
tavorable siirnmiKlin;^* of the yuitient. A^in while the child 
may not he actually demi, it may be morihund, or wj nearly 
tikis as to leave little or no ho{>e of its survival after birth. 



Fig 190. 



Via. 191. 



Fig. 192. 




Vorltius IbriDi of perfbniion. 

le pntiunl 'tr Iier rehuivt^-s. after the ehances and conditions 
have hivii fully explained, will sonietiine** deride which course 
to pursue. In dcliviry by craiiiotoiny the wvcral *^tcph iif the 
oi»emlioii are: 1. IVrforiition ; 2. Excerehration ; 3. C'erhalo- 
IripHy ; 4. Extraction (delivery) of the head, by several dif- 
ferent nietho<lt». 

OjM-njfion. — The fiatient is place<l upon her back on a tiible 
of convcnifut liuitrlit. Every antiseptic precaution to lie 
rigidly foll<>wt<l. An:wthesia is nut necessjiry. though desir- 
able to foretitali unpleasant inemoriesiii. The tirst step is per- 



382 MVTI LATINO OPERATIONS UPON THE CHILD, 

fornlion ' of tlie skull. For fliifl ]nirpose various ** ixrlomton*' 
("pierc^M^ranes") have l)een deviinxl, most of them mmlificar 
tious of "Smellie's sciseore.*' (8w Figs. 190, lUl, 11)2. j 

Fiti. 198. 




Perfnratlou uf the 8kuU. 

The instrument roni^isli?, in brief, of a soipeors with long 
hamllcfi uml simrl hhulrs, the trnninni inch oi* the IntitT fonii- 
irijr a triiui^le wliose a|«x \» the iioiiit. ainl at tlie haw? uf 
which is an elevated maricin, »»r urojeclinp sI»ouhk'r-etoi)S, to 



' Ttic Icrni "rcphulol'miy," fnrmt'rly iisfd Jtynniiyniuiwly wlili p(trftri»lioii, Is 
nlth a furcffs ftAvr. 



hereomlttc«i,«inre Uhiut Ix't-nuinrv rwenllv Hppljt'd iobh omratiun whiclii-«m- 
«lf>is in nmovliiK ihe head by aegmcnta alter dividing It lirom crown u> bate 



MUTILATING OPERATIONS UPON THE CHILD. 383 

prevent a too deep peiietratiijn. Unlike onliniiry R'issore, the 
outside border only of the Ulinle is nlmrj). CareJully guunled 
and guided by tbe fingers while entering the vagina (see Fig. 
193), the point of the blade in made to |)ei]etnitc the tfkuU, us 
Dearly a^i i>os!*iblo at ri.i,'ht antrlos to its jiurfare, to prevent 
glancing otf, niitil further jM'nelralion in arnt^tod by the nlioiil- 
der-fitope. The handles are then mutii|ndnted h) as to o[)en tha 
blades, the outer edges of llie latter thus making au incii<iou 
in the erauium. Alter withdrawing the rtH.-l(wed blade jwiuta 
from the skull — not from the vtigina — the iimtrument i:* twisted 
one-fourth of a eirele uiui again applied as before so as to 
make a crucial incision. It i-s then pushed more deeply into 
the cranial eimty and tunieHl alK)ijt in all direcdous lo break 
up the brain and iti* menibraneH, cure Ijeing taken, if the child 
be alive, to kill it at uuee, by breaking up the medulla ob- 
longata. The [H»tut.sto he preferred for iw-netration nrc, in 
head presentation:*, the jmrietal Iwne ; in face causes the frontal 
bone, orbits, or roof of the mouth ; and in retained bejid fol- 
lowing breeeh presentations, the ba^ie of the oeciput, behind 
the ear, or, if the chin can be pulled down, the roof of the 
mouth a.s in iace eases. 

When perf«>rating a head that is mot\ible at the brim, it 
should be held steady by the liau^ls of an aisistant making 
ext<*nml |iresiure over the alMlomen ; or, if practicuhks the 
child may !hl! Iiirneil and [lerfonilion done on the after-coming 
head. The ojK'ration it^ t^asier when the os and cervix uteri 
are fully dil:ite<l, but riiny lie done when diliitatiun is incom- 
plete, this proeesfl being afterward cxfHMlited hy Barnea'a 
water-bags. 

Besides the scissors, perforators have Ix-en coustructe<l on the 
priucipleof the tre[»hinc. (See Figs. 194 and iy5.) A round 

Fia. IM. 



hole is cut in the cranium, tbruugh which the brain may come 
out, but the scissors are bet^t when it is desire<l to break up the 
bones afterward ; or the more modem |>erfomtor of Tarnier 




Mrnilns trophltie. 




384 MUTTLATnJG OPERATIONS UPOS THE CHILD. 



may be used, especially wLen the ht^ ui luovAhle above the 

Fiu. Via. 




Perfbntion vlth Martin's trephine. 



pelvic hrim. timi the Bciseors are liable to slip ofl from lU 
(^See Fig. lt*«.) 



CEPUALOTRIPHY. 



385 



CoDtractiou of the uterus, together with reftistauce of the 
jielvie walls, iith-r |>erfbruti(»ii, may I'aii.m' (he liraiti tu ooze 
out aud suliicieiitly reiluce the ^Ize of thu heud to mhWvt. of its 



FlO. 196. 




Tariiler'8 pt^iforator. 

paasaire throutrh the i)elvis ; generally, however, furllitr iirti- 
ficial ai*! is iieivssary. 

ExcEREBRATioN (Decereuration ) 18 the next fitpp after 
perforntion. It uieaus removal of the lirniii. This is (h>ne by 
a sctxip I >r spoon pahwt^l in through ihc (i]nMiin^', (tr a ntronjj 
etreiint of ^ltt'^ilizei^ walcr, or prfleriiltly ii warni t to oOOO 
hiehloritle stilutioii, may Iw iiijeeleil wjlb an onlhuiry Dnvul- 
floii'a eyrin^^e and the cerebral am*** w;iblied ouL 

When eollu[)tfe of the heiid after these nieasure« is Rtill not 
suffieient for delivery, we proceed to extract it artitirinlly. 
The several instruments u»e<l for this pnrptwe are forcfji?, ihe 
cephalotrihe, the eriini(K*lnat, the cnttchH, and the l)liintdi(M>k. 

Fvrcepif as an extractor atter perforation may he Uf'ed when 
there is only moderate resi.«*tanee to be overLome. lu bml 
cases of olwtrnction they are apt lu j^lip. nor dii they exert 
Bufficieut compression to flatten the skull, utid hence areeehloni 
advisable. 

Cephalotripsy couBiets in crushing the skull with the 
ccplmlotrilH\ an instrument eompo»*ed uf two tluck, nnrrow, 
solid bla4!es, which are applied singly (like forcepi> ), and af\er 
beinp Iwkeil are made U} ajiproach each otlier by meanK of a 
screw running transversely through the handles, wj that |Xiw- 
erful compression is made ui»on the skull, and its hones 
crushed; or, with<iul crushing, the instrument may simply l>e 
used for compr€«sioD and traction after perforation. (iS?e Fig. 
197. p. 3«6.) 

The field for the use of this instrument as an extractor is 
limited. As a rule, it cannot Iw employeiJ without inflicting 
serious injury to the mother when the wnjutrato diameter 
measures leas than two and tl^ree-ipiarlers inches. 



I 




386 MVTlhAT!KG Ot*ERATlOSS UPON THE CHILD, 

It may lie used to compress the skull Wfore it beooniea 
fixoi] jil thv Urim, ami. an the iiisiruiiifnt Ikto seizes the head 
ol)li*|Uvls\ the noiiseij^K'iit bulging uf the eruiiiiim in the oppo- 
site iiireetioii takes plaee in the other oblique diametiir, 
where there ib uijually mure tt[iiice. 

KIO. 197. 




Oephalotribe. 

employed helow the brim, the instrument ie applied to 
the transverse diameter, \\\\i\ here <'i)mpreis»ion eansor* bullring 
nfthe head in the aiiteri>-|Hititerii>r direeiidu — jimt where tliero 
is iisuiilly letw room thiui anywhere else. Hence, after com- 



CEPJIALOTRIPSr, 



387 



prt^jioii, the h<*a<I ahimld l>e rotated iuto an oblique dinmeter 
l)«fore Imrlion i.s attfiiipteil. 

The o*:phaKirril)e is sotnetimos useful in extracting the alter- 
connng bead where pelvic oootruction in not great. 



Fit;. IIK). 



Fio. 1J8. 





fVtnlrtClut. 



Bniun's oriinlnelABt. 



The Vntuhrhmi. — Thin is uiHjiicstionuMy the /«•*•/ hmtrument 
for fjcltttt'lioti of the |K*rr(jriited hrnd in nis<'H of narnm' |MdviH. 
It niiisiitts of a Blrong, wdid |>air uf lorceiw ( FigK H'^* and VJi^) 




388 MUTILATiya OPEUATfOyS UPON TUB CJIILV 



with snmll, Uufk-lii]i>haiK^fl hhules, serruU'd on their op|Mtsiug 
surfaces. One Mtule goes irntuU' the gkull (ihnniL'h the per- 
rui*utit>ii previoiLslv nmiie), the other nvfrnde, \nit uiukTrieath 
the !ieHl|>, They are iiitroiliuvd separutelv, tsml hn-k likt- fur- 
ceiR*. Whrii iipplied, the iiiHiilc i)lacle, which i? sinnller thnti 
the other ami hiL* no iVtirrilra, apposw* iin eouvex K'rrat<il 
surfw-e ag^aiiiHt the eiinnivity of iUv cranimu, wliile tliu out- 
side one— hirgLT and havinj^^ a feni-slra ajjainst wliieli the 
other may preiw — restn h:* ronoave sernited hurliu'e ujxju the 
convex exlerior of the skull. When the handles are broujjrht 
together after loi'kiug, the IduJetii gra!»p the skull finulv, 
never slip, and weupv hardly uuy spare, since nue is inside 
the emptied craiiiuiii ami llif other imbedded in the Hiil tissues 
of the si'alp. Jjirrratiim of the niatt-nuil s«jft parts iy avoide4i, 
and should the |»U'<t' of ,«kuli irra^ped i>y Lhr iiit^trumeut break 
off, it is eai*y to take a fre:*h Imhl by ihajigbig the jxtsitiou of 
the Idades. Tlius the perforali-d ^kidl in its entirety is ex- 
Irtieted. JShould tfu' [KdvLs he loo small to render tlii< extrue- 
tion p<]»f*ibh% tiie t-raniorhist may lu' nsi'd (o hnak olf piet.'efi 
of Ixjue ami deliver in IrajLiiiienJ*'*. When the whole vault of 
the cranium has been lirouj.'lit away, Ini by Itit, the larger 
fenettlraled blade of the eranaM-last may he placed Ju the 
mouth or umler the ehin, and the smaller blade inside the 
ha^H^ of the frontal bomv ; the inlerveninj^ tissui*s are then 
coiaprt^*it»ed by turning the screw in the bandit's of the instru- 
ment, and the remains of the head turned round so as to bring 
the Hatteued base of the skull int«j the tnui^vers<* diameter of 
the pelvis. The ihicknew of tii**nt*s iiet>\een the skin and 
orbital plates, thus gra>^|j<'d. dws not excee<l two inches, and 
can hence be dniwn through a Hatteneii pehHs but slightly 
exctH'ding that mea:*urement anten>-posterioriy. 

Again, when the cranial vault htis been removed, by the 
cranioclast, etc, extraction of the retnaining haw? of the skull, 
which is too solid to be broken up. may be facilitated by in- 
serting a blunt hook in the orbit, or getting a firm hold on 
the forehead with craniotomy foree|»s, and then, by making 
downward and backward traction. hr'uKjing doum the face. 
The symphysw of the lower jaw is next 4livided, and the two 
halves of the hone pushed aside or removed, when the re- 
maining |x)rtion of the iace, from the alveidar Ininler of the 
upjK'r jaw tfi the rnnt of the nose — mdy nicjisuring H inches 



CEVllMOTHIPSY. 



389 



— may lie uiiuic to cuter the j>elvis, uml dir Wxi^v oi* thf skull 
extracte<l. 

In takiiifj iiway tlic tilcull piccf'nu'nL srnnllcr iii>triitnciiL^ (if 
various j!]ja[)eii ami Hzes — tlie craniniinny t'orct■]^^ (Fi;:». 'iOl^ 
lo 203) may lie ernploywl. 

These diiier from the cranioclnst h\ bfitig siiialler, auti ia 
having their bWea permaueutiy juined at the look, like urdi- 

Fze. 9(0. 



Fio. 200. 





Craniotomy forceps. 



nary t<H)th forceps. The innt-r Burfhreti of the hlades are ner- 
rat^I ; mx\\e are ftirnitrhi, others b<'iir. a! ri^'ht an^^h^ I Fipi. 
202 and 203). They are ummI to ^rarfp, twit't of!*, aii<i extract 
pieces of Ixme, the |M)iut of o»ic hiade goin^ iuio the skull, 
that of the other mih'uic of it, hut nmirr the ^mZ/N this last 
having been i>reviou8ly loosened from its aitacbnieut lo the 
bone& 



390 MVTILATINQ OPERATIONS UPON TUE CHILD. 

In all these onemtioiiH the grent^ care is necessary to 
avoid lacer&tiug the sotl part£ wliile withdraniog sharp boay 

Fiii. aou. 




Stnilght craniotomy forceps. 

fragments. The vaginal wall must be pushed aade by the 
fingers, or, Itetter, a large cylindrical or a 8inia* speculum 




Curred oraniotomr forceps 

used, and the operation conducte<l under the guidance of 
sight iiislead of toucii. 

The crochH (Figs. 204 and 205) is a steel rod, the end of 
which, flattened into a sharp triangular jwint, is bent round, 

rio.2M. 




Crochet. 



At an acute angle, to form a hook. Il is [>asBed into the 
cranium through the foramen magnum, or through a perfora- 



Fig ax'i. 



Crochet. 



don made in some solid part of the base of the skull, and its 
point made to penetrate the bone from within outward, so as 



CEPEALOTRIPSY. 



391 



to get a hold by which traction can hp made. A finger-end 
is placed outside. opiMwite tlie jiouit of (he hook, to prevent 
Iftcemlion in case thL- iriHtrnmeiit sli|Mir t<>nr onl. The **gnard- 
crochet " hai* a second solid bladt* fntlaihtd to the other by 
a "loek"). the end of which tiikes (he plnee of the finger 
iu fitting over the ht>ok to prfvfiit iitjury. Ilovrever con- 
structed, the crotchet is a fornii<hihle iotitrivnnce, and t^inoe 
fearful laceration will otleu occur, detipite all ** guards" and 
care, is now aeldotn used. 

While the hatie of the skull i.s too si.)lid to he broken up 
with the iustrunmutj^ thutt far metitioned. others have been 
devise*! eflpeiMally tVir ihis jmrixise, notjibly the ^'bflsilyst'* 
of Prof. *Sini(«H>n, and Tarnier's "baaiotribe^" The oj)vration 
IB called " basiotripfly/* 

8im|)eou*& iufitrumeut (see Fig. 206) consistfi of a t\A whose 
distal end termiuatee in a conical screw ; both the rod and 

Fio. aofi. 




BlmpBOD'a baall}'8(. 



the screw are split longitudinally, and so arranged that the 
two halves may l)e forcibly »e|Mirated by a device at the 
handle. The screw is jraseed into the skull — through the 
o|tening previously made by perforation — until it come in ron- 
liicl with the base, which, by a boring motion, it is made to 
penetrate until the instrument is well fixed, when, by pressing 

Fio 307 



Slmpcon'ft builfst when sppUcd. 




the two parts of the handle together, the two halves of tJie 
screw sejMirate <See Fig. 207) and break np the hone. 

Tarnier's '* busiotribc " (see Fig. 2(tH) is conHK*e<l of three 
pieces, viz., two strong blades and a central sbaA. The 



392 MVTILATtSG OPERATIONS UPON THE CJtILD. 

central vhnfi-, at \t^ distal ciul. t^riui[tat(% in ii linllow cone of 
f lur liaiN. llu- ji[M.'X of \vlii"-Ii in a H^Ttnv, In liAujx tln' iiistru- 
iiicntf tljo central liar, Uy itiktlt', it- Ijoreti iuto ibe dome ol" the 

Kio. a». 




TarnlcKs bulnlribc. 



skull (perfomtion), then piishc*! on throuj^h the brain, until 
the wrow come in «*onla('t with the l»jii«e and |>fnelriite it* 
The two hinder (one long and one ahori; are then introduced, 



CBPUALOTRIPSr 



393 



one o?i enrli nide of flit: hpa<], iiis f*lnKvn iti Fi;j. 20!l, and 
cruyhiii^ ot" llio ;^kull )»rinlu<'fil by tununn; i\\v rtiinprei'e'ioii 
stTew ji!ii>fe*iug tliroii^li llie ]iuinll*i*. Tlu^ iiistniriicnt J8 really 
a ce|ihalotril)e, with tlie aUditiou of a third hlailc or shntt for 



Fig. 209. 




V\Q, 2IU. 




Application of Tanilor'i bonlotrilie. 



Ba&ititrlpsy scrninptiBhe<|. 



l>rpnking up the l>ase of the fikull. The shaft is proWHed 
witli a Inittoii pivot, hy whirh it is hiekpti seouMy t'» thr other 
hh**ie8 when a]i|ilieil. After imu^ the device suceessfully the 
skull will be crushetl und reduced in size, rs shown in Fig. 



394 MVTILATING OPERATIONS UPON TBB CUILD, 



210 (p. 393), the outline »kutch represeuiing the sliape of the 
comprefiseil cranium. 

iienerufhj gpeakiiig, a |>elviB Piiflicieiitly large to allow ex- 
truction ot* the iioaiJ hv fmniotomy will permit the Ixnly to 
piiss wiiliout mutilntioiL It niny Ix' nwessary, however, to 
pull oil the neik uritil ii Munt li<xjk am ht* piu^H*<l into ihe 
nxilln, liy whirli the shouliltrs — Hrst one, then the other — 
may be drawD out. 

Exceptionally it may ]>e required to perform embryotomy. 

Embryotomy. — This embraces two operations, viz. : evi»- 
ceratioD and ducapiladou. 

Evisceration (Exvisckration. Exenteration) means 
opening the thoracic and abdominal cavities (one or both), 
and taking out their viscera. 

It may, though very rarely (as just cx]ilaine(h. l>f! necpf^ary 
in extracting the Ixjdy al\cr craniotomy, or wlien tliere is some 
ahnormal enlai^enient, or monstrositv. on lite part of the child. 
It is rt'jiortcd to more fretjuenlly in impacted trannverse pres- 
entnlion, arreted "Hjxnilaneoue evolutini),*' etc. 

Operafiim. — The thorax is penetraU'd near the axilla by 
curved soisBors or the pierce-orane, and the thurai-ic organs 
broken up and removed, cithiT Ity instrnniciii.s, or, if practica- 
ble, by the Hnpertf. Thnuiph the KUiie o|>cniiig the diaphragm 
may be perforale<l and the abdominal viscera removed. The 
same care is ueceasary as in craniotomy to avoid lacerating the 
vaifina with splinters of l>one. 

When cvi.sceration is performed i>ub5c<|Uent to craniotomy, 
the iKxiy may he afterward eirawn out by a blunt In^ok ta the 
axilla, as above directeiL 

In impacted transverse presentations the eviscerHte<l \yody 
may l>e delivered in one of three ways, viz. : 1, by traction OQ 
the arm and shoulder ; 2, by passinp a blunt hm)k to the proiu 
and pulling down the bree<^h ; i?, by ^nispiiifr the feet and 
delivering by pwiulic version. Which motle is to !«• selecteii 
must l»e ief^ to the judjrment of the ot)stetrician. much de]>eud- 
ing n[K)n the |H)sition of the child, its size, and the sha|>e and 
dimensions of the fielvis. 

Decapitatjon — sei>aratiug the head ham the body — k 



DECAPITATION. 



395 



retjuiretl iu iiupa<.'te(I slutuMtr preiieutnliou^, or arrested 
"Hp()utaiiw)us evoluiiou," wlii'ii the child in jaiiiiueil tight iu 
the [K-Ivii* un<l cnnuot l>e iiioved up or down. 

Oftf'ratlttn. — (let down an arm ti>r traction, p».ss a l)lunt 
hook around the neck, and while it is held i\t^ low duwn ;ia 
poa;$ible, nibble tlirou^h the vercubruj and aoii partu with a 
blunt-poiuted pair af scisisgra. Cut everything, so that tiie 



KJO. 211. 




PocapiUlioii. 

hook or fin^fcr may be poflsed throu^'h the incision to ascert&iD 
that tho head and bwly are compfr.trh/ soparattxl. 

Another device it* that of a blunt h'M>k. whope inner cou- 
cave fiuritu'e irt nnide nliarp. It is introduce*! while lyinp flat, 
fus shown by the dotted lines in Fie. -Ml. until its end iw far 
enough up to he turned over the ne<'k. The hook having 
been iiasHod over the neck, the latter in ^^eparated by nnrking 



396 



PELVIC DEFORMITIES, 



the Imiitlle of tlie iiifftniment up aiu) down wliile tructiou 

is intifU'. Kof'p a tinjior un the emi nl' llie hook, and reduce 
the traction i\)rv^ \\\\v\\ M«fverarico i;* uwir oompletion, to pre- 
vent injury from Hinhh^ii rohyuse oi' the iiij*lrii»ifUt. 

Other coiitrivamvi* ooiiswl of chains, wires, and strings 
padSKl around the neck, nnd through a h>ng, douhle rauula, to 
protfi't ill** v:i;^niiii, whiU*. l»y a .sawinpf to-aud-fro movemeut, 
the neck in t*everLMl. Iiintead of the douhle ennula, n Hinis'a 
sjieculuni may l>e uwmL 

After deeapitation, the head is pushed up out of the way 
and \\\v IwMly <K'!ivered first, hy traction on the arm, eviaeera- 
tion, etr. Tlie riMoainin^ heail is then extracted hy foree|iii, 
or if required^ hy criiniolonty. In alten»|»ting tlie latter oj>era- 
tion U|Kin a decapiuUed liejid, extra care \» necessary to pre- 
vent xlippin^ of the |>ert'orator. An assistant steadiefi the 
uterus l»y firm jiJulorninal presHure t4> keep the liead from re- 
volving: whilf tilt* in^trnnu lit is Iw^in^ used. 

Finally, in all niulilating npenitittns u|>on the chihl %vhen it 
iVa/irr, tlie clmncei* of a su(vwsful outliufr ojx»ration upon the 
mother for it-«t j*afe removal shimUl first receive consideration. 
In dtH'idin^^ which iNiunte to adopts the value of the wother'ti 
life must l>e allowed the pre-eniinencc. 



CHAPTER XXII. 



PELVrC DEKORMITIES. 

A OENKRAi- study of jMdvic dePjnnity is neceasary, in onler 
that we may learn to ai*certuin — 1\\ least approximately — the 
dt^p'ff and kimi of malformation existing in a given case. A 
knowle<l^e of the firfjrec of deformity indicates whether de- 
liver>* hy the natural pasnajjf^ he or l»e not practicahle, and 
detenninej* the tncMie of assistance hy operative mejusuree. A 
knowIt'd<re of the k'nui of nuiltormation, derived cliietly from 
exarninaliou *»{' M|»tH'inienH in museuniH, indicates what diame- 
lern are most likely to he allere*! in len.irlh, and what |^irts of 
the |Mdvi:* — hriiu. cavity, or outlet — are chietly atfected, thus 
determining: uecessarv uiodilicjitious in the meclmni«m of 



THE SYMMETRICALLY ENLARGED PELVIS, 397 

Iftbor, and indirating the time and manner of rendering as- 

By far the lULWt freriuent variety of deformity is that in 
which there in a nlnniniintj of the conjinjatc (aiiU.'ro-{KtfLerior) 
diameter of the brim^ and while ulight variations in size and 
flha|)e are alnnwit eudletv in numl)er, twelve dbitirul types may 
l>e euuiueruteU, each of which will now be cousidered. 





X ■ ii»U>inmJi>r pvl V Is. il. Snrtoal tnter-vreiUldtometfir. CJutto-mfDor pelvis. 

1. The HYMMimurAhLv KNi.AKaKi> Pelvis (Fki.vi8 



398 



PELVIC DEFORMITIES. 



-f^OABiLiTER JrsTO-MAJOR). — Shape ualunil ; size, in all 
ilirections, incrttajM-il. (Swi Fig. 2V1.) A uoupeuilal comli- 
tioD. Ijitbor ia apt to be onnatn rally rapiil, with cou^tM]tieiil 
liability U} inertia of the utcnis ami posl-partal hemorrhage, 
ami there ia increai»wl temiency to uterine displacetiifiits. 

Trratmrnt : Confine the woman to the recnnik'nt |H)sture as 
soou as labor begini* ; rupture the membranes early, before 
(he OS is dilated, and enjoin resiHtanee to Ixyiring-duwn effort:*, 
that labor may be prolnnged. Extra care In 8e<'ure uterine 
contraction <liiring third stage of lalwr, (five " Predpitate 
Labor," Chapter XXIX.) 

2. The SYMM^r^RICALLY CONTRACTKD PELVIS (PELVIfl 

iEQUABiLiTER Justo-minor). — iShajje natural ; &ize^ in all 
directdons, lessened, ifiee Fig. 212.) A congenital variatioiu 

Fia.218. 




Adalt pelvis rcUlninff its Infknllle tjrpA. 

Labor difficult or im^to^ible, aewirding to <Jegrce of contrac- 
tion. Occurring in dwarfs, children may aonieUmes Ijc boro 
without difficulty. 



'^. TiiK JrvKNii.K PicLViP, — 8ha|)e resendde^ the pelvis of 
iniaiicy and childhood. ("See Fig. 2K1) It ia mi arrcflt of 



TEE PELVIS OF RICKETS, 



399 



devDiopment Transverse measurements relatively Hhorter 
than the cotiju^ale, owin^i Ut uarrowness of sacrum. Sides of 
|H'lvis miimturally straight, puhii: arrh narrow, ami isrhia too 
near together, l^ilmr iliffirnlt or im(Ki»*ible pro re mita, 
hi pret'04'ioua mothei's Lime may remedy ihe defonnity. 

A. The Masculine Pelvis. — Somelimes ralle<l "funiiel- 
fihaped." It is deep and narrow, reHt-mhliiiu: thai of a male, 
the narrowness inoreiwing fron) al)ove downward ; heiuie ol>- 
strurtion to hihor, most mnrk*>d townni the outlets The |x»lvie 
Iwnes are thick and solid, a condition thought to be produced 
by laborious muscukir work only suitnhle lor men, 

Fio. 214. 




FUt nohiUc pctvlB. (Muucr Museum. College of PbrBicUns. PhtladcIphtA.) 

6. The Pklvis of Ricketb CRArnrris) (See Fig. 214). — 
The /t/;>iVvi/ nichitie pelvis is the most rommun and mopt im- 
|H)r1iint of all def'ormitit'H. The jttdvir bpirn in shortfowl nnteni- 
|)oslt'ri<»rIy, the «itTum sinking' flmvu Ih^Iwwii IIk* ilia, and hav- 
ing its promontory tilted J'oruard toward the pulie:;, thus 



400 



PELVIC DEFORMITJE& 



producing the ''JiQtfentdjjein^:*' — i. ^^ il is flattened antero- 
pt>f;tC'riorty. the putstcrior and auteriur |telvio walla approach 
each other too cloeely. 

With the forward tilting of the saeral promontory (as if 
the whole £>£U'nnn liad rotiitetl a little uti a transver^ axiA) 
there iiei^'i'rwjirily (K-eurs Invckward proje<'tioii of thf«*e sepmeniB 
of the siKTUiii irmiiedialely Ijelow the promontory: In fact 
tlii.s |iiirL of the Ixjiie projet^-t^ ho far huokwurd^ a» Iaj heeiirne 
ahinLst hnri/.ontal. (8c^; Fijr. 215.) At» or ahout tlie juno- 
lioii ul" the 4th and 5th saeral vertebrae, this haekwanl projee- 
tion abrnplly ends with a sharp liend forward (also seen in 
Fig. 215;. Thia l>euding forward of the lower eud of the 




BacblUe pelvis, with bsckwartl deprcasion of aympbyKla pubis. 

Bacrum ("and coccyx) iit partly due lo its heiug held baek by 
the sacro-sciatic ligaments aud other attaehnientB. and {>artly 
to the sitting or semi-recumheut poeture 80 frequently assumed 
hy rachitic children who are too feeble to walk. The concavity 
of the rtacruni w leHsened from side to side, ami may even lie- 
come flat or convex from forward pn>jectiou of the boilies of 
the up|ier Racrnl vcrtebrw. 

Most of all must it \te note<1 that the normal relation be- 
tween the Icn^rtb of the interspinouB and intercresta! external 
mea*urement» ( IM and lOi inches re«i)ectively ) it* foM — i.e,» 
instead of the inter^piuous being an inch shorter than the inter- 
crestal. the two are nearly or ({uite alike, or the inter!*pinous 
even measures more than the inter(Te«tal. This ii* due U} the 
win^*^ and crests of the iliii. which, inntcad <»f ninintuiniug 
their normal degree of vertical elevation, become :^pread out 



i 



TUE PELVIS OF RICKETS. 



401 



Intornlly, hontv the antorior (»iii>prior i^pinoiii* prt>cci<ee8 iMHronie 
fiirllier a|>art. The rami ut' the piilies become flattfiitd, the 
pulm* arch wi<icne<l, arnl the im^hin tlivorj^c from each other. 
Tlie total result ifei ; a ultnUow ptlvt^ with coutrachtl brim^ and 

There in ofteu a relative lenj^theniiip of the tniusverae 
«lii\niftt.'r of the Urim, which nii^ht 1ki C(mi(K*nsalive, were it 
not fi>r tho fart that the j>elvi^ of rickety suhjectn are usually 
unilersijMjti ah initio, hence (he leri^theued Iruusverue diameter 
selihiin exf.'ecdj* the iiornuil incjisurenient. 

Tlie wliole oimtour of the j^lvic brim usually iM^Jomee more 
elliiJliciil, or ki(hiey-«ha[»etl, varyiug with the dej;rec of autc- 
rior pnijtx'liou of the sacral promoutory, (i& showu iu Fig. 215, 
in wliicii there has also occurred a deprezssioa of the pubea 
tVniii traction by tlie recti musclcfl. 

Ou inspection, a rachitic woman, standing erei't, shows ynju- 
leriorly, a transverse depre^ssion t^ahnost the be^iuiiii^ of a 
fissure ) acTOiii* the back produced l)y the backward or horixoutul 
projectiou of the sticrum, while, fniiu tlie same cause, the nor- 
mal verticid inlcnuitiil fissure is so far obliicruted a.s lo render 
the anus viable. 

8u<^h are tl»e ntiuaL, and nuwt pronounce<l chftracteristics of 
the typical nwhiiic flaltened |>elvis. More rarely all sorts of 
variations o<*cur; thus, conjointly with the foreffoinj/ alterations 
ihen^ may be intend e\trvuinrf of the spine, hence the scoHo- 
rarhitir^ |xdvis in whieh one acetal»ulum is pressed in, protluc- 
in^ irrc^nlar and oblifpie dcfonnily, owinj; lo the curve4 spine 
causing the |»atient to walk with the weight of tlie body more 
on one acelalniluui than llie other. Again, if the rickety 
chihl, witli its soAeneil (telvic [tones, l>e able to run alnrnt, the 
weight of iu Ixxly falling equally u(>on both acetabula. then 
both sides of the pelvis will l)e preflseil in, protincing a de- 
formity resembling that of osteo-malaeia, hence called **p8tudtf- 
mfiltifoHtmn*' or '*/wi/*»<//>-m/t/«c(Vi." Sf*. possibly, we may have 
a rickety hifnuHie |>elvis, or a rachitic 'Ujrueralfy vontrftctt'd'* 
pelvis, and many other con»plK*atioi»s. But these are loiusual ; 
the comumu rachitic jtelvLs, with conjugate fhitteuing, iw first 
above described, is the one from which we get most trfMjble iu 
oletetric pruclice. The degrct of olistruction has no limit; 
in slight cases it is moderate : in Imd ones su great us to make 
C4r»arejin soc*tiou a nei'esaity. 



a 



402 



PELVTC DEFORM rriES. 



Besides the rrirAt/iV fliilteuec] peU'is there occurs quite fre- 
quently, a riiit |K*lvis without rickeU* : tlir uon-rnrhitir jiat jtflnjf. 
In jM)nie nmnlrics nC Ktiro|K' it i?* saiil to In? more otuuinon than 
iht- nirhilir vnru-Iy. FortiMmtt'ly il s«'l(h»n or never pnxi litres 
very tjreat olK?truttioii, the ctjujugate ilianieU'r is sturfely ever 
Icitft than thriH' inche.s arnl iti inoist (tisofl it ih three and a half 
ur throe ami three-i|uurter8. 

The oh^truetioii i^ itrtxluceJ. m in rioketa, by sinking down 
of the tuacTuni between the ilia, but, wr/like rieketM. the sueral 
pronjontory does not pnye^'t forward t»y rotation of the «w;rum 
on itti truuHverse axis, hence there w no tihinjf huekwnrd of 
the sjicruui Itelow the proniuntorv. Nor is ihere any ex[mn- 
sion at the outlet. The sarruni (wliich is usuaily smaller than 
UKual) fc'iniply sinks downward, heuee what liltle decree of 
olwtnielion-wcurs, occura in all ftfirts of the ]>elvi9 ; 8Uj>erior 
and inferior straiLK wa well a.s in the cavity. The lateral wulls 
of the pelvis do not Hare apart Intend ly, hence the nonnal re- 
fation between the inlenqnnoiut and intorerestal external uieaa- 
urenientb is preserved — i i\, the intercreslal reniaius lotiger 
than the intertfpinous. 

6. Thb Malaoopteon PKi.vts ("soe Fijrs. 216 and 217") r^ 
suiting from (ist<»onmlacia — a uniform s«>ftening of tlie l>onc8 
oeeurrinu in ndnlt life. It may c*)nie on in women who have 
previitusly l)ome children without difficulty. Its progress 
l>eini; gnulual, the }>atieut i» able to wafk aUmt, hence press- 
ure of thitrh lK)neta in acetabula puithce in the iiidis of tlie 
pelvis, shnrteninir the tranmrrnr diameter. Anterior Iwrder 
of |>elvic brim hai* a s|M.)Ul-»ha|KNi or lHiake<l ap|>earance. Ex- 
ceptionally, and in very batl fuw-rt, the oblique and (H>nju)^t<i 
itiameters may l>e also wntraeteil. Oteonialacin is alwut 
four hundreil times less freipient than ricketi*. Craniotomy 
or Cie^arean Keelion may lie re^piirwl for delivery. Kometimes 
the S4)ttenetl Ivneii yield aud admit the passage of the- child 
by other methods. 

7, The Oblique Depohmity op Nabqelk (see Fig. 218), 
— The «M'n>-iliiU' synchondrosis *)f one side is anehylost^l. the 
oitrri-spomlinif win^j of the sarrnm atrophiwl, or imjuTt'ectly 
developed, ho that the acetabulum of this side approaches the 
healthy sAcro-iliac synrtiondrosis <tf the other, shortening the 



THE OBLIQUE VICFORMITY OF SAEQElt 403 




Osteomalacic pelvia, witb bcak-llko shape of pubea. 
Fio. 217. 




Oatcooialadc polvla. 

oh1i(iue diameter lielween these two points. The other obUque 
(Jtanu'tori eturting from the diseaticd Micru-iliuL* liyiiehuuclroHiH, 



404 



PELVIC OEFORMITIES. 



is lengtheDed, owing to the aymphyHis pubis and acetubulum 
of the health)* side l)eiug forced out of place toward the suuud 



Kw. 'Jl». 




Oblique tlefuimUy of Katrgel^ : dlwuv <m /(/I side. 



nde of the ineiiian line, 
paratively rare. 



This variety of deformity is com- 



^. TiiK "Roberts Peiab" Tsee Fip. 219).— A double 
ohlit)tie deformity. Httlh sarro-iliao .«ynrhondr<»o8 nnohyloeed, 
and b*Ah wiii;.'^ of the KifTuni abwmt or uudeveloped. The 
brim is oMonir ; |H'K'ir sides more or loss |>nnillpl with each 
other; ischia presi^^l towtird each other, and sido« of pubic 
arch nearly i>arjdlHl. Transverse dianicter i(;i(iviwi//y short- 
ened at brim, wivity, and outleL ObHtriirtion very ^reat, 
re<iuirinK (.'cesarean section. It is really the oblique deform- 
ity of NaegeJe occurring on lioth Hides, and is extremely 
rare. 



9. The SpoNfiYi.oi.iKrnFrric Pelvis (see Fie. *2'J0). ihie 
to forward aud dowmvurd dislocatioa of the lumbar end of 



THK SPOXnYLOLrSTHHTfC PELVfS. 405 




ThL> KubcrtH pclvU. 
Fig. 230. 




BiMindyioURthctlc pclTta: 4, fourth liimlnir vcrtobn; &, Rftb lumharrrrtrhnL 

iKlUAM.) 



406 



PEL VW DEFORMITIES. 



the spinal coIuihd, from its proper place of support on the 
base of iho .satTum. It protluceH markt^I contrattiou of con- 
jugate diameter of the hrim, anil, owing to siicral promontory 
l)eing force*! somewhat backward, the !1ik*x of wu-niiii may be 
tilted forward, thus lessening conjugate diaueter of oulleL 



FlO 22L 




The ky-|*tu>tic pelrlt. 

Degree of obstruction very great, Kometiniee requiring last 
resorts in operating. 

10. TiiK Kyphotic Pklvis (see Fig. 221 ), due ti>barkwnrd 
rurvalnre of the sjMiial oolunin near it.s lower end. rulicnt 
short in stature. an<l. of course, '* huni|>-lt:irk<'<l.'* The siicnil 
pronioniorv is nli.Hpnt or drawn backwanl out of reach, thus 



DEFORMITY FRt^M JilP VtSKASK 



4o: 



letu^thcjiinff (vmjugalp iliaiiieter of brim, l>ut wniraclintj iia 
trantfirrjic niejwureiiieiit. The ajK'X of sacrum is tilted for- 
wanl, tiiui llie iwu is).liia lunl two yiilen of |>uMr arrh approach 
each {ttUvr, t*o tlmt «// the Jiaiut'ten* of the oiUlet aw\ some of 
the, cavity are iiiiiiinished. Obistructioa chiefly at the inferior 
stmit 

11. Dkformity from Ihv Disease face Fig. 222). — 
Coxitis (iuflamniaduu of ihe hif)-joint;, occurring iu early 

Fio. sa-i 




Obliquely c<ititnict^-<l (•vlvtit from coxaliria: coxUih vn rlxht aide, defumilty un 
left. (MiUU-r MiiMvum, CuIIukc of PhyRlclaofi, PhiladeliihiJi.i 

life, causes the pntieut to rest the weij?ht of the hoily ou 
the healthy {u\\ while the lame one \» not ui^A. Conse- 
quently the healthy aide of the pelvis ia gradually uusheil 
over toward i\w diseajMHl mde, pro(lucinff an ohlir|Ue deformity 
rosemhlintr the ol)li<jue }>elYia of NuejreK*. The earlier in life 
the dise«i«e l)e>jini* the greater the defornnty. In Fig. 222 the 
ritjitf Hide in the diw^iu^Ml one; the /'/if half of the pelvis, 
having 8upj)orte<l the weight of the iKxly upuu the left ace- 




J 



408 



PELVIC DEF^JRMmES. 



Uibulum. » posbeil tncr tcivard tl»e rtghl sde. Thitt that aide 
of tlic pelvM haTiD}? the mormuU bi[tjoint u deformed ; the 
oibi-r uue no< bo. The deformity is not ugw»ify tnfficieDt to 
serioti&ly ol«truct labor, but n^ be so eaceprionally. 

12. Deforscity frum Exfjerosis, etl-. (see Fig. 223). — 
iSony nnd ueteo-eaminuitou:^ luniurs groving fruni pelric 
Ijoiied — niotit *.>ften from fr'ini of e«acrum — prxyert inlo pelvic 
<!uvity aiid priNlure olistniction. R<Hiy projeciioD^ a1:M occur 
from callu^s resulting from fracturv of the booetf. The ischial 



Tm, 




Bony tumor of aacnim. 

Spines are sometimes too long, and eDcroacb upon the pelvic 
canal. 



Orijinary Symitomj* ok Pki.vic Pkkormity wrrnouT 
KKi'KRKNrK TO ANY Si'K«;iAL (^'ahi:. — Previous history of 
diilioult laU>r«, and of the di8e««« or atoidents by which 
iH'Ivic di*f(>nnity is prtKlur*^!. Early recojjnition of quirken- 
lu^L by llif piilinit (third niniith). PeuduluuH M\\. In- 
cn-nHPtl obn<juity siml inoliiliiy of the pretrimnt womb. Orentor 
liability to nuiI|jrt«ent)ilio]iti and to preueutatiuu and prolu|iee 



ADnmoyAL symptoms in special cases. 409 

of the funis. During ]alK)r the fingt^r can l>e more easily 
iutnxhuxti lu'lvvtrii tlif lijs* of tlie c>s uteri ami bag of waters. 
Os uteri iiiovuhle from *^i*iu to biiie. Pretseiitinj? purl high U|n 
or out of reach, when Itrim contracted. Pains intense with- 
out ()roiK)rtionute i)rogress iu destrent of jireseuting part. 
Later, "arrest" of the hetid (it tletioemls no further), or "im- 
paction" (wheu it cannot be moved, either up or dowuj. 

Fig. 224. 




Grcenbalgh's iwlvlincter. 

Caput sucMMxIaneum unusually lar|je ; its gradual swelling 
may l>e mistaken for progress in dewent, 

AnntTiovAi* Bymptoms in Hpkcial Cahisi, — In ricktts: 
"bow-le^," curved spine, and other deformities of the skele- 
ton, with history of rachitis in ejirly liie. 

In vnttomaiaeio (mal«cosl**on ) : pn>hahlc history of previous 
latrar without dirtieuUy, the dist-ase hcginniiig soon arter a 
delivery. Symptoms of osteomalacia are: pains in bones of 
pelvis and lower lindm; l>ones tender on pre^sure^ especially 




410 



PBLVIO hEFitl^MiriES. 



ovor symphysis pubis. They are also pliahlc, yielding to 
manual pressure tliiririL' hiW. OM-yiaiHliu^' casts of hip 
diseajte prebeiil previous history oi* t'Dxalgia. The diogiioeis 



riU. 225. 




Baudelovque'scallpen. Tills fiiruni Kl«ishitwv Cuutouly'it pvlvlmeteriippMwL 



in the aliuve iraM.^ luuBt be ctiiiiirnied. nnd iu the other 
varieties nmile out ainioet eiitirely, by nieiisuring thf jielvia 
(PelvinK-try;. 



VhLVlMICTRY. 



411 



pELVfMtrrBY may be aof.'Oi»»|>liglie<l Iwth by iutornHl an<I 
exlenuil nieasurenieiiU*. The be«t yir^r/mWer (j)€lvis-nir4isnrer) 
is the hnufi. 

To iiK':i.siire cotiju^iitc ilinmeter of the brim, ptusi iudex 
fiiif^er uiKler pubic arch and rest its ivMiit aj^ainsl JMifral prom- 
ODtory.' (8ee Fig. 2li7, jmge 412.) (It iti uot possible to touch 

Via. 226. 




Collycr'if pvlvlinotcr. 

the promontory in a normttl pelvis.) With a finger-nail of the 
othtT han<l make a mark on tho examining finder where it 
toiiciies the pubic arch. Wiihtlraw the finjrer and measure 
(with a rule) fnmi tlie mark to iU tip. From this meiu^ure- 
mcMt deiluct half an inch, and llie remaining lenpth jBrives the 
CDUJu^ale (liani(!ter of tlw brim. The lialf-iiuh is siibtrarU'd 
beeanse the leii^jlh i\» measured from the promontory to the 

■Takenre not lu mMnkc ihv (Aonifilinm iimmlncul) Junction of dm ai»1 
MWMHt MCml vurtebne fur lUv real pntnumUirx 




412 



PELVIC DEFORMITIES, 



under HUrfot^e of the pubic i*vmj>hyHi« (the (iiatjnrial coiiju^te : 
see Fig. 4. [>age 2H) is half mi inch longer than from the prnin- 
oiitory U) liie upptir snrfat^e of (he piihir joint, the hitler hoing 
the brim mea^urenient it ih ileture<l tu auctirtiiiu. During this 



FlO. 227. 




IVtvimvtrf with the finger. 



exurniniUiuD the woman should lie on her hack with the lii[)8 
elevuteil. 

Thi« measnrcnieul may lie fa(.'ilitate<l l»v using two fingers 
iu8tea<i of one. The tip of the midille tinger touches the prom* 
ont/>rv, wiiile the iiiilex finger re^lfi against ihe pnl>ii' sym- 
phyiitis. A iinger nail of the other han<l miirk;; (lie jKiint on 
the index where it toui-hei* the puliie juini, and afterwards a 



EXTERNAL PELVIMETRY. 



413 



rule measures rhe dbtanfe aorust^ the two fingers as shown by 
the liutit'*! lint' ill l-'ifr, 228. 

Auulher uielliud : Pjitieiit lies on her left si<le, uear the 
edge of ihf IicmL Kthurize. it' uertrssriryf to |u-eveut [miii. In- 
trodu<r;j entire liaiul into va^^iim, and disi]x>Hn it (hilwiMj with 
the liitl(» HiiiTpr lowjird syin|)liyj*is piiliis nnd thf indti-x-finpfer 
apiinst Harrul |iri>nii)iilorv. Loarii how muuy linjrer.-* win tliua 
be .'<imn!l<ftirn!t.-<'if introduced liHwet'n the two |Mjintjs. The 
breadth of four liugi'rs, in u hnnU of average size, i:; ahout 




Ufftsiirliig tlif dinj^onal uunJuKnU< with two fingvn. 




two and three-<innrt.ors inches. The finprers introduced may 
be ftfttTwunl rneiutured by a rule. <See Fi^'. 221*. \m^v 414.) 

Of the ouiiiernuj* instrunientnl pelvitnetert* fur internal um?, 
thtwe of Dr. Luiidey Earle and Dr. (ireenhul^'"h (Fit'. 224» 
j»ai;e 40i)K are probably the Ut«l ; but they «in scan-ely Iw 
li8e<l durioi,' hdH>r. wlirn iniist often nt^ed, and jrive no better 
rewnltj* than the hand uhiIit any eireuniMtanre?*, 

The trnuAvrrAr' and oUu^iie <Uanieler3 of the brim can only 
be roughly estimated. 

External I'klvimktry. — The pelvimeter of Baudo- 



414 



PELVIC DEFORM ITtES. 



locque, or some moditif'utioD of it, u general ly uflerL It is a 
pair of L'ircular cali[»en^ u scale uear the biugu Indicatuig the 



Flu. -/as. 




M cunrlng Conjugmte diameter with wholo hand. {A ftcr Datb). 



]..uinley Kikrlc'B prWiuirter. 

Space Helween the open ends when applietl. (See Fi^, 225, 
piijrc 410.) An inexpensive iniftrnment is that of Col Iyer. 
(Hee Fig. 22(>, puge 4\\.) 



OBLIQUE DEFORMITY OF XAEOELE: LtAGNOSTS. 415 



To ineafiun? ronjiigate (liaiiK-trr of hrini, the woman Iviiig 
oil h^^r Hitle, |ilufe one j)oint of llii; iiistruniiMit ii|K)n llie ujip^r 
tnJ^re of pubie M'i]i|»li\>is, uiid i\\v oIIkt ti|»|.)0!*ite «ktu1 proni- 
onlory — (. ''.. over the ilf|iresBinn jtist Imlow tipinoiis process 
of lutit luinlmr vertehru. ftnje Fig. 22.3, page 410.) Nor- 
mally ihw sliouhJ liu-nnure 73 inohu*. DtHiucliug 3i for thick- 
ness of lK)nt^ and hott paiit*. leiivet* 4 int'hii^ — tlie nnrnial lon^Mh 
of the brim's <-<>iijug!ite diameter. The degree of reduction in 
lliiA DteiiHiirenienl, allowing for individual vnriiLlion from 
obesity, «lc',, will give, ujrjnoximfU*/if, the aniouiit of pelvie 
omtra<-lion, but a limited reliaiKV oidy i*nn be pince<l u|K)n 
this metliwl without other C4)rroborative evidenee of dc'f<trmity. 

In uMng iLt' <>di]H.r» let the lliund* and index finger of each 
hand gni^p the little knob on each nrni of the instrnntent, so 
that the terniiiiul emls of finger, tbnndf and knob, aft touch 
the ei-iii futjether; then with a nundier of little lateral to-and- 
fro motions, the finger and thundi readily /er/ the itoiuta upon 
whiih it is <lei*ire<I to place the knobs for measurement. 
Having done this, hold the knobs in |K>sit,ion. while iiis|)e<'ting 
the w-'ale near the hinge of the ewlifierss to ni^certiiiu the dib- 
tanee between them. 

Two otiier external mea^urenientx are important, viz., (1) 
between the two anterior superior spiuouH prooe^ses of the ilia 
(normally IM inrhe«) ; and {U) between the most laterally |»ro- 
jeetiug [toint.s on the two crcaU of the ilia {normally lOi 
ineln»»). When Ihi|)i me»wuremeiils are reiluoed it indicat^ifl a 
uniforndy eontructed |)el\iK. When the inter-4'reftnl measure- 
Dient is normal, or only a fiftft dindnished, while the iiiter- 
gpinous one iH increaj'etl, it indicutee a pelvis with conjugate 
eontraction of the l>rini, but oliierwise n<»rmaL When itoth 
niearturementfl are deriiit'tiit/ diminished, while the inlcrspinous 
one exceed}* tlie inter-orestal, other diameters are contracted 
be0ide the ej>njugate. 

DiAcNoHis OK THE OfiMtiirE Dkcokmitv or Nai:*ji:i.e. — 
l^irneueHH, from in»|UM[ity in the heiglit of the hi|i^ If two 
plumb lines \)e sus|)ende<i, one from the centre of the sacrum, 
the other from the symphysis pubis (the [laticnt stamling 
erect), the pultic one will deviate toward Ihe healthy side. 
Measuring from the spinous prot'tiw of the last lundior ver- 
tebra to the anterior and |Kwt<erior spiuouis proceesea of the 




PELVIC DEFORMITIES. 

ilia, will Bhuw a reductiuii of hall' an iucb or mure on the dis- 

side. Anntoinicttl fenlurea of the dofonnity, already 

^deacribed, to be further nitulc out hy vaginal examination. 

DiAONOSis OF THE KYPHOTIC PELVIB. — Meusuratiou 
rt^vi-alri nnirkwl nurrowiujr of s[iaoe Iwtween tuherot*ities of 
the isohia, lK.awt*en ie<*hial Hpiuous processes, and between 
Bides of pubie arch. H|MW.*e between anterior superior spinous 
pi*oce:*se!i of ilia, i]e<.*i(ledly increaseti. Alieence of sacral jTroiu- 
ontory ami other anatomical characters revealed by vaginal 
touch. Humpback visible by iufipcctiou. 

DiAciNofiis OF Spondylolisthetic Pelvis. — Figure 
peculiar ; thorax normal ; alxlonien short and sunken l>e- 
iweeu crests of ilia, the latter widely separated. Aonio pul- 
sations felt through iKwterior vaginal wall. History of violent 
pains in wicrum at puberty. (?) Vaginal examination revcula 
dislocation at liuero-lumbur artienltitiou. 

DiAON'OKis OF " HonEKT'H Felvis." — Owing tonanrownen 
of WKTum. the ^imceH Ijetween the two iliac crests, between 
the two iliac Hpinws, between the two !ro<*hanter^, and between 
the two itu-^iiial tulKTt^ities are all reiiuce<]. The two {Ki^terior- 
8U(ierior iliac spinous processesi, especially, approach each other. 

DiAONOSLS OE Mascitlin'e Pelvib. — Mensuration demon- 
8tratc» dimininheii width between pubic rami and l>etween 
iwhial tul»en^itie», etc. No obstruction of labor at suijerior 
strait; head afrej<led in pelvic cavity. 

Dangers of Pelvic Deformity. — Te^iioue lalwr ; shock ; 
exhaustion, and inertia of uterus from prolonge^l contnirtilo 
efTirt^ Inllanunatioii, ulceration, and Hloughing of maternal 
soft |mrts fn>m contu.-iion and pn>longe<l pressure. Child'--* 
life jet>pardiiEe<l by pnjIajsH^I funis; by ctmtinued und exagger- 
ates! coniprciiision of craidum, e!ii|)e<'ially against sacral proui« 
ontory. Ojienitive meactures for delivery nuiy neeertiilate d©*] 
rtnictioD of infant. 

Modifications in Mec hanism of Labor when Conjit. 
oate DiAMi-rrEK ok Brim only m Contracted. — Flexiou 



k 



MODIFICATfOXS IM MKCIfAMSM OF LABOR. 417 

is impertet't. The ()cciplU»-frontal ilianifter ni' heat! oroupies 
trun:*Vf'r8e of pelvic hrint. Tlio l)i-|nirit'tal dianutcr is rilu-d 
H) tliat one end is lower iliaii the other,' hence (lie antrrhr 
jmrieliil boss presents near the pultes, while the jtoHitrior one 
lA tilted backward uud iipivard toward (HX>lerior ithuulder, 
which carries the sagittal suture toward the sacral promon- 
tory. (See Fig. 2'^\.} Thus anterior end of bi-parietal 
<lianieter is permitteil to descend before pisterior one ; there 
is not spa<re for inith to enter iimuUnneoiuly. The somewhat 
wetlge-shaped sUUa of he«d inipingiui^ against prtJinonlory 
and pulieti, uow cause oc^ciput to !^ii[>, lat^ralhs toward that 



FlO. 231. 




HeAd pAsaing tbrouKh iiilei la tlal pclriii. (After Parvik.) 

ilium to winch it poiutM, thus bringing the narrower bi-tem- 
poral diameter (3i inch**) to occupy the coutraclcMl conju- 
gate in place of the wider bi-parietal one. As dcwcent thu8 
proceciis, the forehead and larger fontaiielle are lower than 
Occiput and small one; but. later, dexiou ticcurs, which liriiigs 
cKvipnt down on one wide of [ndvis, while forehead ris*-." up on 
the other. lu this way the briui is pa«*ed, when, the chief 
difficulty Iwiug over, occi|»nt n)tnt*s to the pul>e8, and labor IB 
comjdeted lu the usual nmnner. 

< TtiUlati'rnt tlUlng of ttic fmvl \* fomctlmn omkcn of «s1tio*''>W<'/'''^1^ 
SttfiftU;" It Is «|iilu> M'lAmle rriiiii. nthl Iimn iiuthlliiC to do wllti. Uic dliUqiM 

lU'f'iniilty u1 \\\v ftftvu dttcrltn*! I»y .Sin't:t lt\ 

a? 



418 



PELVIC DEFORMITIES, 



Modification's ly Mechanihm of Labor when Pelvis 
18 I'mfokmly Contkacted. — The head nmy enter iti any 
lielvit' (lianuliT, ihou^Ii usually in the oljli<juf. Flexion is 
uniisnally miiiiiU'Ir, t*o ihul (ictipiln! pole oi' orcipiio-nieutal 
(Uniiieter jioiiiis almost vertk-ally tluwn al right iiii^^U*s to 
plane ofHUpcrior strait. (Seo Fijff. 231*.) The "uMi.juity of 
Kflegele" is very j>lij:ht or al>.«eiU. Both parielul IxtsHrs eritrr 
at the wime litne. Snuill tljiitjiiielle iound near centre of 
pelvis. Should train-verse uurrowiujr ('(tntiiiiie toward outlet, 
the ejctreme jtex'ton coutiuuen \\\i\\ liahility Ixi iriipartiou auJ 
arrest; hut if the ptdvm widen heloiv the brim, the exagger- 
ated dexion letseus^ aud the occipital [tule of the Lead leaves 

Fig. 2S2. 




Varked flexion of head entering agcDCTally eontraeted pelrts. (After Pastim.) 

if« central popition, and rotates, in the more favoralde cases, 
toward the puhej*, when delivery follows in the u.«nal way. 

Modifications in Mechanism of Labor when Pelvis 
IS •• Generally Contracted" with Antkro-posteriok 
Flattening, — In ihi:* case we have the " Naegele obliquity" 
of dattened j)elvi», joined with the exaggerated Hexion of 
justo-niiuor cfl.*m«. The occipito-frontal diameter of the head 
usually occupies the trausverse diameter of the pelvis. If 
delivery be pojwible, strong flexion causes the occiput to de- 
scend Br8t. 



Defects in MirrnoDs rei^uibino Rixtikicatios. — lu 



DELIVERY IN PELVIC DEFORMITY. 



419 



pelvcfi with very nnrn»NV roiijiiffnto ami hifrh proniontnry, psjie- 
fially, but »ometiiin*s in utliors that are IfK-^ ?*o. tin* " olili<|uity 
of Naegelt ** is oiTf-ilone. Tlic |u)st*'ri<>r parietaJ bono ia 
directed too strongly lownrd |»ostenur tilntiildcr, tni that napt- 
tiil KUtnro may l>e even 'i^>tv sacnil pnHiJOiitory, aud the ear 
lie tell just l»ehind pubic symphvsiin. In Ihitleufd |>i*lvfH with 
transverse shorteLdng, the olilnpiity [tniy be ihe utherway: 
the fHniitfiur jiarietal Ifont* prcfii'niiii;^^, ilic puirillal hiituic being 
tuwani or even al>c*ve the pubis, while an ear i.-* i'At ueiir 
Itromontory. At'iiin, the prtijMT dclirit^ney <>(' Hexion iit the 
early Bla^re ol' hilwr \u liattent^d pelves may l)e overdone, thus 
lending to brow or face prei*eniatiou, «nd iu which anterior 
rotation ( nsij>eetivcly ) of forehead or chiu wiU be iiiUHjaable 
later ou. 



Durin)); breech deliverie!!^ in coutracted pelvpe, the arms 
mav !>e di!4phn*e<1 to tiie rfidea of tlie head, and this InHt may 
lie iinliirlunately extended by the eliin nttejiin^ against the 
j>elvit' brim. In marked transverse shorteninjr, exten/iou of 
the eliin iu lireech cahee^ makes delivery im[HjH8ible without 
jjerforatiou. 

Methods OF AasisrriNO Delivery in Pelvic Deformity. 

— Exehidin;;, for the prestnit^ the induction of lafwjr l)efore 
full term {to Ik* wmHidered iu the m'xt chajiter), the resourees 
of the olwteirieian iu jielvie deformity nre : For^-ejis, version, 
crnnidJomy, t'awarean stH'lion (or one of ita allie<i utHlomituil 
0(»erati()ns), and symphyseotomy. 

The fletinition of prccUe rules tor deciding which of these 
>rtHT<lureM must be selected in u given ira>e is a (juite impood- 
>le uuilertakiny:. Of the amny |M>inti4 to l>e eonsidereil, one 
of the moflt imjwrtant ia the iie;;rree of ahortenin;^ iu tlie con- 
jujTiito (liameter of the superior strait In so far ws this ia 
coneertie*!. it may Iw stJiled us a general ride, which, however, 
must be aiusinled suttieient eliistieity to allow of its eonfonn- 
iug to other elements of im|wrtAnee hereat^er noted, that 



When conju^te diameter of 

brim measures — 
IJetween 4 and 3i inches, 
Betweeu 'M and 2\ " 



The proper mode of delivery 

at tenn is — 
By forceps. 
By version. 



420 



PELVIC DEFORMITIES. 



Between 31 and 2\ inches, 



Between 2i and H " 



Below It inches 



By symphA'seotomy w^iM for- 
ceps or version, if tliese 
two la8t-imnie<l operations 
fail triihout it. 

By alidoiiunal seotion, or, if 
child he (h'atl^ hy crani- 
otomy. Syiiiphypcotoniy 
tvith craniotomy as we aj>- 
proach the smaller figurea. 

By aUlorninal aeclion, not 
cninioiomy, nor by fiym- 
ph\*8eotoniy. 



As l>efore statcil, and as a matter of course, selection of 
the nicthwl of delivery must nut depend ttoU'/y u|)on the length 
of the conju^irnte diameter. SiiK-e we winnot during labor 
measure the |»elvis exadhf, and still lt«8 the chiid't* head, the 
im[X)68ibility of inathcnmticid rules for practice is painfully 
evitlent. 

Furthermore, no two eets of caees are exactly alike, and 
the ex|>erience of no two prnctitioiicrs exactly similar ; hence 
hardly any two authorities exactly agree with regard to the 
pelvic meai5urements determining the kind of oi>eration to be 
employed. In c-iu*e8 with the ianjrr iiguree above mentioned, 
the operation calleil for will be comparatively easy ; with the 
smaller nieiusnrcnicnLs, more difficult. 

Among the host of other coiifnderatione upon which our 
selection must, in part, dcfiend, maybe mentiouwl : 1. The 
kind of contraction ; whctlier Co) himple antero-|Kt6terior flat- 
tening, or {b) general contraction, or (c) Iwjth of these com- 
bined. 2. The .site of contniclioii : whether at brim, cavity, 
or outlet. 3. The estimated size of tlic himd and its degree 
of ofipificaliun. 4. Whether or mil it hr "urrcst*Ml,'* or "im- 
jjucted " (and at what |»oint in the |»elvii!<), or have parsed 
through lilt' m uteri. 5, The amount of dilatation of the os, 
and the Btate of the mendiraues. 6. Ketractiou of uterus 
nlwve the head with consequent vertical tension of vaginal 
wall, 7. Is the child dead or alive, and, if the latter, will its 
lifr bo jcopfirdized or h«*t by tliu proi»<ie*eil o|»eralion ? 8. 
lli.*»Iory of former lalMirn (if any ) and rei^ultH of metlKHis then 
eniploywi. 9. The n nmbft oi previous deliveries, as indicat- 




^^^^^^^v 


^^H 


SIGNS OF FtETAL hKATIl /A' VTERO. 421 


itig: pre^t'iit lnlK)r-|«i\ver, H). 


Kl.l. :SB. 


Immiiu'iit ilan^rer or .'iciiinl (w- 
rurreniv of uU'riut* rultturt^ 


r-FNTlMFTRFfi INHHES 


1 


1 1. ( ieucrul condition of woman 




- 


»H repanirt lier ulnlilv t<> survive 


1_ 




the pro|)(>fud ot»eralion, 12. 




— 


The •' presentation " inwl •• |K»i- 






tion" of Ihe chiUI. 13. The 


a_ 


* 


existence of coniplimlions, such 




1 


utf heniorrhiipo, i*<'hini|».*iu, pla- 


3_ 




ccnUi pr*L*vui, |irolu|j>tMi funis. 


_ 


etc. 14. Tlu' frtliinnlt'tl kn(»\v|- 






etlge, nctjuired nkilL iiud native 


4_ 


— 


dexteriiy of the oiM'rator. to- 




^_ gether with (what it? not orten 




- 


^B sufficiently con8i(lere<l ) the kind 
^H of haud he ba])[>en to |M)KHeH<, 


5- 


.2 




^H whether tinmll, Huft, ami pliahle. 


L 1 


^H or the revetve. 


6_ 




^H An upproxinnite t«tiinate of 




_ 


^H the fize and cauyiMfnnj { hard 






^V or Hoi^) of the rhihJV head 


7- 


- 


^m may he ohtniue<! hy exiornal 




3 


^K [lalpation over the lower alnlo- 




^B men. In thin way uIho ntay 


8_ 




^H we ascertain whether the wideBt 






^H (hi-pt^rietHl) diameter have or 


o 


^H have not entered the hrini. 




^B and whether it Ik? {Hiet^ihle 


^m to force the head into the 


loJ 4 


^H brim hy munnal pretvure from 


^H ul)ove. 






^B Ab much must dejiend u]>ou 


11^ 


- 


^P whether the child he alive, we 






^" Tmiy here note the Higm* of ilfl 




~ ! 


iK-nth. 


ia_ 


- 


HiaNS OF FocTAi. Dkath i» 




5 


l^TERO. — Some of thcec have 


13 J 




alr<*tuly Uhmi menlioiii'd in the 


Hclatlvo iM*iili.' nf IneliM and 


chapter ou *' Abortion" (page 


ucuUiuut«fB. 



422 



PELVIC DEFORMITIES. 



173). Ailditionul ones reci)|^inxiil»Ie <luriiiji: lulM>r are: C«»sa- 
don of fii'tul lu-nrt-ftiuiinlrt utter tliiv have Im?ou [irevionsiy 
reco^nizeU ; ceissutiou ui' qirickeiiiug, i^|H'i'mlly wlum iiniiie- 
tliaUily [treccHlt-d W irroitcuhir arnl luinuhuoiis iVrUiI motions. 
The tJiarliar;^e uf iiiecoiiiiiin, wlieii the <*at*o is /(o/ a brewli 
preaenlaliijii, in of .some sij^^tnlu-anoe. In head preseuUition 
the i*cal|> w soft and Haliby ; the urauiHl Iwnes are kwjse and 
movable, and may hv: t'ett to grate agahiHt or overlap each 
other more than nsiiiil. No rafint vurtnlottcitm is formed 
during hilwr «inw tliere is no eirctilation in the walp to |iri>- 
duce it. In ijyrt'A ojwes the anal sphincter is rehixed and 
does not contrarl on thL* linger, hi J'atx caisty ll»e ]if»* anil the 
tongue are ilahliy and niotionles.-*. In arw |iresentn!ion the 
living limi> is warm, ixrhaiin somowhat livid or swidleii from 
pressure HlH>ve^ and it may Ih^ made to move ; not so the thad 
arm. lu fnttia presentation the living cord is warii^ Hrm, 
turgid, auu pulsaLorv ; the dead one (vhl. Haeoid. empty, an<l 
pul»elet». Some of the above Kijriw, it will be evidetil, eaa 
uoly oetmr when the child has h(*en dead some time before 
labor — the condition of the scalp and cranial bi^nes, tor ex- 
ample. 

In any doubtful c»#e where the hand enters the uterus, it 
may feel whether the ci»ril pulsate ami lH^w wtron^rly ; or feel 
the precordial rcgiuu of the child aud thus recognine its heart- 
beats. 



Methods of Dklivery. — By far the mart common, and 
therefore, to the ^renenil practitioner, most important, variety 
of jjelvic deformity is that in wliich there is simple flattening 
of sli<rht dejjjrce, at suiKTior strait (conjugate of l>rim measur- 
ing betwiMMi 4 and ''\\ inchi^). Some of these m</y he delivered 
without artilicial aiil, provided the p:»ins bo strong, the pre- 
sentatiun corrwt. and the me<-hanism follow its normal course, 
while other conditions are favorable. Sliould symptoms of ex- 
haustion begin (see Chapter XXIX.), or complli^tions render 
speedy delivery necessary, the usual mode of assistance is by 
forceiJei. Shouhl judicious efforts with forcejw fail, symphyse- 
otomy will enable them to succeed. Kxceplionally as when 
head is very large and is arresterl high up, or aUive the brim, 
and cannot be made to enter it by mamni! pnrssure, even in 
theee slighter ca»es of tiatteuiug, version is preferable to for- 



METHODS OF DELIVEHY. 



423 



ceptt, espe^rmlly ^lieii iiieiiil>rtiu(*e are uiihriikeii, uixi oh uteri 
not sufficiently itilutcil to render f<>rL'ej)s aiivLsahle. 

Id the riecomi degree oi' simple flatteuiug (conjugate be- 
tween 3i aiul 2] inches), we can ex|)ect neither i*]H>ntaneou8 
delivery nor sac*.'eK*fiil ibrre|is dt'livery, unless the child be 
UHXiSiMtly small. Version xn here the most u?ual mode of 
proceeding. By Turning we bring the narrow part of* the 
heuil (iLci hi-tern|H)ral diameter. 3i inches) to engage fird in 
the conlriuied conjugate, which the wiiler itvmt- of ihe fikull 
«>uld not do (i*ee Figs. 234, 2'io,t, while ajicr luniiug the 
skull is further narrowed laterally by pre^ure twtween the 
jxilTic walls, as shown in Fig. 285. Sloreover^ aficr turn- 

Fiu. :£M. 




^ 



Pt(i. 234.— t^v«Uon r<r ruftAl Kkull. showing tMuc uitrruwrr IbAn dome. oo. Bi- 
pMrieUl (iJamifU-r. Ui. fil toniporal diumelbr. 

Fio. iia.'j.— Further narmwiiig of ernnium by prewiire aftL-r turning, aa, Oiil- 
line of skull U/orx Trraiun. bX'i. Untlino offer turning. 

iug, manual abdominal pressure from above may be ronjoine<l 
with traction on Ihe child's IkmIv from l»elow. In cases where 
the conjugate diameter n])proache3 the lower figure of 2J 
inches. syni[ihyHeotnmy may pre<'ede version uideas the head 
he iindersi/rd. The chief object of versii»n, here, is (o deliver 
a llviiiff child. If the infant die during version our design has 
failed. Heuce, should it be dead alrea<ly. or very likely to 
ilie during ven^ion, |)erfomtion would l»e preferable. If a 
living child ainnot pas*, it ift nsele^i* to wait ff>r its death 
before we perforate. Aftvr turning. crauJototny may Ptill be 
required for the nfier-eoniing head, but «mld this huve lKH?n 
anticipated pertbralion bejoix version would have l>eeu belter. 



42* 



i*EhVW DEyoUMlTiES. 



Many n|lJ^I«t^i^•iatl^ do not wuulkm vernioii at full U^'ni wlini 
llic (*oiijutrate is lej<s tliMii :•{ iix'lies. Furtliennoro, slmiilil the 
lieaii liave pn.*H<l tlie us uteri, or luive (.li'K'eiuled iutu tiiu 
|wlvk* cuvily, ur it" it reijiiire fon*e to lift it hack aliovi- tlit* 
brim, orsIuniM llie uttTu:* lie rutrat'tttl abovt* il (jiultiii^ the 
vn^iiia oil ilie j^lr<*lrli). or eiu|Hie<l of liquor anuiii ami tighily 
gru^piii}^ tiie chiKiV ImmIv with imininent dan^rer of rupture ; 
under any of tliest' 4'ir('uni8taiK*<?# versJion hi'<'omc8 extremely 
hazardous, and jK-rforatiun may he preferable ; tlioufrli l»efore 
lliitj liu*l, a lentaiive applieatiou of force]? i? perliajs barely 
justiHable. lor tbe child's sake, if it be yet alive. Peiforaiion 
may hIw> be avoided by retorting to tiymphyf^.'otomv in these 
cases l)efore attempting version. Siilije<tinjr the niuiber to 
the dangers of au nbdonnnal siction for ilie ^nke uf ibe ehild 
csuinot in these ejise» l>e favorubly eont'ith'n'd, although sueh 
a course 1ms \\^i\\ advised by some recent autlutnties. 

lu the third tlegree of tlatteniu^: U'onjii^aite of brim \y^ 
tween 2\ und \\ inohesj force] s and versicm are out of the 
qU(«tion (we still sp**ak of full-term ens*-**). The choit-e here 
is between ]>erfbration and siinic torm of abdominal section, 
ybould tlso child lie alive, and if it have not l.een injured by 
delay or by futile atlein[its to ileliver in other ways, and pro- 
vided tbe general eoi»ditiou of the motlier. ber hyjjienie sur^ 
roinidinp*, her capacity to secure skilled attendants, etc., be 
such as to lend substuutial hope of her surviving the ab- 
dduiiuat section, this operation would \\q justitiable — the con- 
Henl of herself and relatives thereto having been previously 
obtained. I'nder op|x)t)it« eireu in stances, craniotomy. It 
must* httwever, be remendiere<I that contraction of the con- 
jugate below 2j inches mddom (x^curs without either (ffiid'al 
contraction or narrowing of the ttinnnerse diameter, which 
must nmterinlly iutluen<'e our nro<!e of pniceeding. 

When the cnnjugute of brim is sl.niter than 1 il inches, th«* 
difficulties and dangers uf crnnioioniy are. beyond all qtieiKJ 
tiou, greater than those of ahdoniit.ul section. 

Id a tjeufntfltj coutrttchd |)elvis. a Hrimj, fuil-terni child caoj 
scarcely be <leliverp<l through the vagina, either by forceps orl 
versitm. unless the conjugate measures at least Si inches. 
With slight ilegrees (»f sm-h contraction, fon-ejis or version 
nmy suceeeil. When tlie conjugate is 2 iuchet*, but with a 
transverse of leas than 3 incbESi Ciesareau section is almost a 



TJih: ISDVCTIOS OF PnEMATVRE LABOR, 425 

mutter uf iieoessity ; ami when tlif^ro in jrt'ueriil amtrat'tioii to 
the extent of 1 iiirh hi c^uli din ctittii, tlu- nlH]i>ni(njil ^xriion 
WJuid prolnthfjt Ik' Iji'IUt tliiitJ cTaiiuttomy. 

tShoulii the fieail, in luiy (:tti*e, Imve tlesoende*! into the pelvic 
cavity, or have readied the lower strait, craniutoniy would, of 
course, Itp It-ss objtrtionaMe. 

In porforniin^ version in vxircme jttnto-viinor ciiat-A. dilHoulty 
with the after-romi)nj head i» otteu very great. When the 
genera! r<^lii4'titni in one inch in all the diameters, we can 
aeareely deliver it even with the |>erf(>nitor arnl eephulolril)e. 

Once a^ain, he it distinctly understood that nicas»urenientii 
of the (lelvJH alone cannot he taken jw jiruidw* i'or ))ractice. lu 
selecting the niethinl of operntinL', nil the circun»stance,s of the 
t^aae iniiat receive due cifUHideralimi. Kxccptional cai^es re- 
corfietl in lKX»k.s, of »!ucces.sful (Udivcry through very small 
pelves, hy exceptionally skilled oinrators, are uni(pje ftoHotibU- 
Uieit that cannot he Uikeii jih guidei* for general pnictiee. 

lu cajtei* where the pelvis will not atlmit the delivery of a 
living fufl-trnn child, the hirlh of a living infant iniiy Htill !)« 
pfwsihle hy (he induction of pit:mature luW, which in consid- 
ered in the next chapter. 



CHAPTER XXIII. 

THE INDUCriOX OP PREMATURE LABOR. 

By the end of the twenty-eighth week of pregnancy the 
child is sufficiently devBlo|x«l to he CA|>ahle of extm-uterine 
life. Delivery U'tween the lwei»ty-eighth week and full term 
is called •* premature labor ; " before the twenty-eighth week, 
*• ahortion." 



Cases ly which it is Proper to IxorcE pRKMATirRE 
Lahok. — 1. In |*e.lvie deformity whore there is sufficient space 
for a seven months' chihl to lie deliverer] without injury. The 
ohjwt 10 twofohl : (fi) to save the child's life hy ohvinting the 
ndoesBity fur crnniotumy ; (6) to spare tlie mother the dangers 



426 THE ISDVCTION OF PREMATURE LABOR, 

of craniotomy, Cosarenn sf<'tion, Etvrnphj'seolomy, or other 
oi^rutions (hal. nuiirlii he re<]uirt'(l if the pri'^imiicy woui to 
full term. 2. In ca?*?* when', in prcvitnis liiUirs, tlie head of 
the rhii<l at full term hius liet^n preiiKitiirt'ly (IH^iii^(L or umiflu- 
lilly lar^t.', k* thai hilmr liai? In.-*'!! iHHu-ull and dnugeroiis, even 
ihough the |M'lvis were iiorinid. Tin- fH-riod ut"*Kdiv*Ty need 
ouly Iw Iwo or three weeks lifforf •■ lenii " in lhe,«*i caties. 
3. In cases where the tdiihiren of |irfvion8 itrej^nuncies have 
diwl in nU'vu during; the later weeka of jretJlatitm from disuse 
(fiitty, calcareous, or amyloid tiegeneration. etc, ) of the pla^ 
oeota. 4. In condjliouft where the eontinnanw of |iregnauoy 
seriously endangers the mother^is life, such as: excessive vom- 
iting ; albuminuria ; iineniic convulsions, or |iandysi» ; choren; 
mania ; orgjinie di.seuM; of the hear!, limgHt liver, Idixxlveesel, 
etc., threatening fatal diHturhauee of tlie n^spiration, circula- 
tion, imd other vital functions; irrerlueitile dif^phicemenls of 
uterus; placenta pnevia with hemorrhage; amlin dungeroua 
presr^ure ujKjn neighl)onng organs from (iver-<lirttenlion of 
uterus, due to dro|isy of unmion, tumors, multiple j)regnBucy, 
etc. 



Induction of Prematurk Laror in Pelvic Deform- 
ity. — In jifii [>elveH (the more cfutimon rnehiti<' deformity) 
the tlegree of eonjuLrale <y>ntnictiou in which it is [irojier to 
induce prenmlure delivery, when it is dej'igiied to save the 
child's life, is praeticully limited to l»et\veen 'M and 3i inches. 

A child, at the end of the seventh lunar month { 2Sih week), 
tnny he delivered alive through a conjugate diameter of 2^ 
inches. 

One at the end of the eighth lunar mouth (32d week) 
throngli M inches — |K>ssihly, through 2f. 

Otie at the end of the ninth hniar niouth (36th week) 
through Si inches. 

Wiieu the measurement is over .Si inches the labor may be 
led till full term (^i)th wtH'k). 

In firuatdhj rtfutmrtn! |n'lves, when alf diameteif are short- 
ened, the c^Hijttgale nnist measure at leib<t otic tfuaricr of an 
itwh hnffcr than the (igures given above, in order to allow the 
same rules of o|>eratiog to be followe*l. 

Owing to the difficulty of determining exart size of the head 
and pelvis, the more precise rules given in text-books are 



METHODS OF rSDUCIXG LABOR, 427 

prarlirjilly utHOfSi^. Fiirtlurrijure, it is not alwavfl easy to 
nwertj»iii willi prrriititni t\u' ilunilicni of propnaiKy. The gelec- 
lioii of'auy wtok iiiltM-uu'diaU' »►!" the jievioils aUnvc notftl must 
be luil to llu' jiiiigmt'tit of* l\w ol>ML'tric-iaii ami limdeil Uy the 
cir<Him>t*mfvji ut' euch rase. The nmst nsuul lime ior lirin>riiit; 
on luiKir. nil ihin;^ fousidered, i& hetweeu the lidrty-scrond uud 
tliirty-ibiirlh week, 

111 any cast* with a n»njiij;:ate of 2] iuciies, rhanees of saving 
the c'liihl's liio are rxceeilinj^'ly ^nlall : ImjI. mh craniotomy, 
syniitliyi^foloniy, and ahdoniina) st-riion are tlie only other 
nieuUH avaihihle, the atleni[)t oti^ht to lie made, delivery heing 
aide<l, if neee-^siiry, hy version, or hy smatl toreejis — a dimin- 
utive instrument liavinp lioen e^JUHtnitied ftir this |iur|;of*e. 

When iht* eonjujrate diameter mea.«iireH tt'.<is tlian 2A inches, 
abortion should Ik- indiieed j*h wxjn ai* |Mi*iihle after the diag- 
uwi» of pregminey ii- eerUiin. When the ttjiijiiffate diameter 
meusureri \^ inehe.s, imluetion of ahortion must not he |M>fit- 
|Mtiied later than llie h<yiniuni^ of the iwenly-first week: wlieii 
1 i, not later than tlie iK-i'ianinji of the wventeenth week ; and 
when only one ineh, not later ifian f(airte*'n weeks. If, Imw- 
ever» the woman ( lieiiii: <■hildl^•s^, or i'ur oilier reasonn) prefer 
to risk the dangers of a rutting alMKnidnal ofieration, and thfre 
are no ^>eciul ei^eum^lall<'1ts rendering' >iue]i a eoufKe ini-nliarly 
iiiadvi&ialde, the cane may Ik? ailowe<l to jio to term, and the 
ehild then extracted promptly hy seetion through the abdomen. 

Metiiot>s o^ Inducing Labor in early Preonancy 

itKroitE TiiK Cmi.i) IH ViAitUK. — Two meth(Mlc of inducing 
aliorlion in conmion use during the early niunlhs are: 1. 
l>iiatatioti of (he os and cervijr xUeri: 2. Puncture of the amni- 
otic itar. 

1. lHhifatiim of <Vrrij'. — Tlie vagina and vulva, the hamla 
uiid intitrumenlji of the ojierntor, having been rendered aseptie, 
a tupclo or landnaria tent ( previoiiply sterilized )' is [iimfied well 
up into the eervix with a pair of dressing forceps until its 
up|M'r end |>eiu'trate through the internal t»»* ; it is kept in 
plaei> by a tampon of iodoform gauze plaee*] beloAV the exter- 
nal QA in the vagina, and there allowed to remain. In a few 
hours the tent al>sf)rbs moisture, mirNji, and thus dilatea the 
cervix t«utiiciently to invoke uterine conlraelionH i pains), 
t ^>o«j/f tciibi arc no longer used; lb lalinpttisibleLoBttirUliwiliuiti Ihoroughtj. 



428 THE INDUCrroS OF PREMATURE LAROR. 



This method Hecurtw prwtervatioti of the Inip of wait* r. whicb 
ttitlsi .■-tili.mHjiU'nt ^Tt'JVttT *lilalatii)ii tif the o8 jiiid cervix uteri, 
and tavi»rrt ilitwlmri^e of eutire ovum — fielu;*, placenta, aud 
memlmuicH — :dl at one time; and also tendfl to minimize the 
amount of iu^iuorrha^e. 

2. Pitnrhire of thf AmtiMc &c — The sac is rupturei:! by 
introduciiiir a uterine wtiind, or wme olhor similar iiiHtrumcnt, 
into i\w cavity of tlit* womb, and turninjj: it uliont therein until 
the H«|Uftr ainnii **s(-n|>e. The nietho«l Ls more often iwetl crim- 
inally than for iK'iurlicent |»ur[j*>se:^. It is |>erh»|it* the woret 
of ail method*, and iriust certjiinly never he em|)]oye<l lute in 
pregnancy when it is deiii*rned t-o siive the chihl's life, for dia- 
eharj|[e of the "waters" sulyti-li* the soft and inanature fiielus 
to fatid <5oniprft**ion hy contraction of the uterine walls during 
deliverv- 

iSnrffii^il Mttluui. — It hxs l)een recently recommended to 
trejit the ovum !w if it were a niorhid jrrowth and remove the 
content.'* of the uterus hy a surjo^iil of>eraiion. 

After tlturouifh iliKtnfertion of tlie aUiomen, vn^rina, antl 
external L'cniuilia. as well rw of tliu hands and iiiHtrnments of 
tliL' o|M'ialiir, the (Mitient is ana.^!theti/<^d. A t*|>e<*ulnni is 
intHHlucrti ; the anterior lip of the uterus sleadieil hy a vul- 
»(?lluni torcejist, while with a steel branched dilator (Goodell*9) 
the <w and cervix are hIowIv diluted to the extent of one or 
even two inches. The whole hand i? then passed into the 
lYttjitut^ while the index finjrer slowly goes into tliu nteruis until 
n^acliin;: the fuudns, which la«t in pusluMJ, hy iil>doi[iinul prea^ 
ure, ileeply down into the iM'lvic cavity. The entire ov»un — 
nipnd)nin<'« and everytliin'r — i.s then jieelod or 8cra|»ed from 
the uterint; wall with the tin^'er and extraeteil. In eaiie the 
wond> cannot Ix* snfHciently depreaw)! for ihe tinker to reach 
the funduH. a lon^^ curette may tie iiecil to twfninite the ovum, 
and itn extnietion aeeompli^hcd l\v the fiuj^er or ovum-foreops 
aiU'rward. ErpU und njruprcHrtion may he necewsary to tvn- 
irol hemorrha;re. Tinally, the empticl womh U thoroughly 
wai*hcd out with a 1 to oOOO .solution of hichioride of mercury, 
or with a '■\ (kt n-nt wilntion of creolin, after which a drain 
of Htcriliw^l j:au7/' is piissfd lo the fun<lu.s, and the prm'ewlin^ 
w fiui(*he<l in short order. The gJiuze to he rernov^Ml in sixty 
hours. 

When the cervix in ri]^id and refused tu yield to the finger 



METHOD OF jyDUCJNG PREMATURE LABOR. 429 

or steel bmnchtHl dilat^ir, the cervical canal (having been 
dilated as I'ar vns pnu'liraMe by tlief^ inethofln) is t4tiiffe<! with 
steritize^l (rauzo, wliich rtftor six or eiglit hours so far liof'lnis 
the tisKues of the ft-rvix as to aHow of roinjjiftiiijf the rnjiiircfl 
liihit^ition with the linger or iiistrimieiit, \\\wu the ojuratior* 
in proiMH'dtHJ witli iiti In^fore dcMcrilje*!. While this tiiethod 
com|MjrU with the reigning surgical bia»? of tlie age^ tliere are 
no pru*>fo AH yet that it is better than oliier autiaeptic lumles 
of inaiiugtiig ahnrtion uuieH. 



Bkst Mi-rrHon ok iNDiiffNo 1'kkmattire Laror when 
IT IS I)ksi*;nki> to Savk the CiiildV Life. — After thorough 
n»e|»Bi8 of vagina, vulva. itMtrunieiiLs. (.*tr., [mihh into the uteruH 
between it« wall and the fu'inl nieinbruuet* — with great nire 
aud genlknies:*, to avoid rupture of s:ic and disiurbauoc of [ibi- 
centxi — au elai*tir urethral hougie ( uiore easily reudereil awptic 
than ft hollow catheter^ to a length of 7 or 8 iueljes within the 
OS. Ijet it remain there (kept in place by a vaginal tAinfion 
of imloforru gauze; as a foreign iMxly to invoke uterine con- 
traftion. 

To iwcerlain the |Mrsition of the idaeenta, with a view to 
avoid disturbing it with the bougie, it has lieen lately recom- 
meuded to map out the fnllojitan tulx-s and round ligaments* : 
if they comtriyG antrnorhj^ the placenta i? on the jMt^lrrit/r 
uterine wall ; if they are para/fff to the longitudinal axis 
of tiie uterus the plaL-entu is on the uiUetHor wall of the 
uterus.' 

Tn intrmlmnng the Iniugie the woman should be placed on 
her left si<ie in (be hitoro-])rone ixw^ilion, with bi|»t< near the 
e<lgc of the he<l. A Sinrs s(>e<'uluni is used ; the cervix 
rteadittd by a tenncuUnn or vulselluni forcep in the anterior 
lip, while the iMingie is piirtsed up and guiilcMl into the oh uteri ; 
then let one tiuger folluw it up to the internal oh and defleel 
the i)oinl to one side, »> as to avoid injuring the bag of waters. 
Thufl guided by the finger of one hand it is puwhed up with 
ihe other. With the oe uteri of a prinijiara it may l)e neees- 
wirv to dilate it with the steel branched dilator, or with 8«»- 
tangle tenths, ijofore inwrting the bougie. Inntead of using a 
spe<*n1um, in the 8imH position, the woman may remain on ber 

■ l^irxild (ititle^ thMi lilt; currnitif^it urOiiii \W-v> Iikh lici'ii vernird by numer- 
ou« Omwivan Mvi'tloiui. 



430 THE lyDVCTIOX OF PREMATCnE LABOR. 

back, and thi> Uoupe lit? pussed wp, grui^peil in u lung pair of 
uterine (lres>iii^ — ur |H>l_vpUi* — rorce|«i, and guided in l>y tl»e 
iiiigers ns ju.sL de.seril»wl. IC, in twenty-i'onr huurts iit» eH'wt 
Ik; produco<l f which rarely hainK^ns), take it out, and a^ain 
intrtxluco it iu a soniewhai diH'erLTit dircHTiun. and leave it ns 
iu'fore. L lerine omlnutiou.-^ eventually iM-eur, when the 
int^irunient is removed, and, if tlie [Jtiiua iuerease iu strength, 
the «ise may he lell to nature. 

in the coutracliuu:* l>e only fueiile and do not increase iu 
strenjjth and treipiency, accelfrate both thrm and dihilntion 
of the OS, hy intriHiuciuLr elH»*uc diljitorf? ( Bameg'n water- 
bagsj, first a small one, afterward larger tiizes, into the 



Fig. £16. 







Barnee'ii bag for dilmtlag the t'errlx. 

cervix. No other nieasurej* will fjtnmifhf l»e ret^uired. One 
of Barnes's water-haj^s, with its attached tuU* (ut*nally a fool 
in length) removed, is shown in Fig. 236. The hag is intro- 
duce<l I the woman having heen placed on her l»ack, her lower 
lindtti flexed, and hi|is near edge of lied) hy ni4'ansof a uterine 
s>und, the end of which Is inserted into the little jK»cket fixed 
to the buir neiir its up]>er end, or it may l»e foldeil and ;_'ras|K^d 
hv a pair tif ^Ire^^ing rorcejts. |)asse<l juft into the cervix, and 
pushed up further with the fingers. It is next filled with 
vMit»T (not with air) by a Daviilwjn's svringe. the cajmcity 
of the hag having lie^u previously learne<l, so tliai it Ik? not 



METHOD OF jyDUCL\G PREMATURE LABOR, 431 



distended to bursting. A string tied tightly around the tube 
retaiud the water. 

Fl«. 237. 




Dilator and forceps of ChUDpcUer tie KlbM. 

A mrMlifio4l dilntor, inveutpd by Cbnmpotier de Ribes, diffem 
from that of RariH's in being larger (Si inches in diameter at 
the baee;. r>f conical shape, and made of t»ela&tic water-proof 



J 



432 TUE ISDVCTWN OF PREMATURE LABOR. 

eilk. It is iuiriMlucetl with a spet'ifll curvetl forceps, as shown 
iu FijLT. 287, |«i]Lre 4til, 

It rcmninj- iu eitu until exjM.'Ilc<l by tfie pains, wheu dilute* 
liou will Ix* sufficiently coiiifiletc lo allow of delivery. In 
cn>i«s of [wlvic narrowing this dilator must not be <listeuded 
lo iti* full capacity, hut only h) fur lu* will allow it lo paaa 
«u*ily tlnv»u«rh the coutnicted canal. 

If, when the a^ is r/v// tiilattii witli the larger bii^, uterine 
<*oulraciiun \m etill delayetl, the mertibrunew mtnj lie rup- 
tured. l)Ut then delivery nui«t l>e htv^tem^il, usually by getting 
down one foot liy the Hrnxton-Hickb method of version, iu 
order to save the child's life, 

Otiiku >Ii:Tii*»j>s: Thk Vauinal Douche. — Place the 
wonifln iiixiii a Wd, her hijis near the e<lge of it and resting 
ou a rubber cloth, iu whidi is arranged a gutter to guide the 
returniti;; tbjid into a vessel ou the flw>r. By means of a 
founlain-syringe, Dnvidpon't* syringe, or a rubber tul>e oon- 
t)ecte<l with an elevate<l vei^Hel, direct a wtreani of warm water 
mja'uid the cervix uteri. continnouHly, for tifteeu aduutert, 
three limes a day. at intervals of wx hours The nozzle of 
the syringe must gu atjtthiffi tlie nrck; never info the mouth of 
the womb. Tem|K'rature of the water utwut 100° F. From 
four lo twelve, or more, injections may be necessary. The 
woman nee4l not keep her he<l l>efore hibor liegins. A modi- 
fication of the vaginal injection i** known as Cohen'e inethtKl. 

OohenV MKriKHJ. — Thij* consists iu passing an elnMic cath- 
eter between the meniUrnncs and uterine walli^. and injecting 
warm water i»low]y. iu (pjanlity of seven or eight ounces, into 
th> utrrus, preferal)ly near the fundus, until the jMilieiit feel 
some distention. I^I>or comes on much nittre certaiidv and 
rapidly than ufler the vaginal douche : but Ua\i these metlKids 
have caused Hudden death, and Dr. Barnes, with whom many 
other pra<titi<mers agree, avows ''that the douche, whether 
vaginal or iiUra-uterine, ought to l»e abp<dutely comlemneil ns 
meann of inducing hilwr." 

Tun Vauivai. Tampon. — Distending the vagina with a 
latnjion, nr rublier bag hhiwn ii]i wilfi air nr water through a 
Stopcock (the colj^utynter of Brauu), is another means of ex* 



STERILIZED GLYCERINE: UTERINE INJECTIONS. 433 

cilin^ uterine coiitrai'tion. arnl a niiiijiiiaitivtly liiirnilcrw one 
wlifu nirel'nlly uwil, Init williul puiiilul, ami uiurrtaiii in effi- 
cacy. The lif-si Uimixtii b* a cuiitiuuoutJ f-iri|i of iodotiniu tT-'Uixe, 
thort>u;;lily parkutl round the cervix and hehiw it, till the 
vagina l>e full, the wmmui hein^i^ in the knee-ehej*t jxiiisition or 
m Hinis' poHture. U shnuld l>e renioveil in tweuty-ioiir lioun^, 
and. ii' rH|iiisite, reiieated after wajsliing out vagina with auti- 
aeptic j^diition. 



Utkkine Injections of Rterilizkd Olyckrine. — A re- 
(leut method of inducing lalwr consiht^^ of injwtinj; hetween 
the uterine wall and biig of waters fnmi one to three ounces 
of uteri lizf'(f f/h/rrrin. It aclH Jiy producing a nipid exosnioflis 
of fluid from tlie amniotic «ic or from the uterine wall, with 
CH>u«Mjtifnt separation of ihe niembrHnea and production of 
lahor paint*. The glyoerin is »teri]i2e<i by hoiling. AtW 
pro|ier antiseptic precaution:* the wonuin is placed in a knee- 
ch('s»t or laten*-pn>ne [XKsition; a ruhber tidte or ehiHtic cath- 
eter i.H parsed to the fundus, thmugli which the glycerin is 
introduced fitluT by ^'ravitjilion from a fiiTuicl or by a syringe* 
care being taken to exclude air. Tlie tuiie ih withdrawn, the 
vagina jnuked with i4.Miofonn ^nw/je, and the patient kept at 
rest for w.'veral houn*. In wnie caset^ labor pniiis come on 
within an hour ; and if uot within four or five houn*, the injec- 
titm nmy l)t> repeated. Half an ounce bua been Kufficieut iu 
wnie iuHlancei*. This metiiod has not yet been Hutficieutly used 
to allow of a fMisiiive decision iu* to its merit. Ry wtme it is con- 
sidered THcertain, and has been supixised to prwluce nephritis. 

The use of ertrot and other oxyt*xics; the iujecliou of rar- 
Iwnic acid tras into the vagina : the imiuction of uterine con- 
traction by electricity, galvanism, alwlominal frictions, irrita- 
lit)n <tf the nmnnnary glands, have in turn all been resorted 
to for bringing on premature lalwr, but cauuot now be recom- 
mended. 

Whatever metliod is used, the n»ain purpose of the opera- 
lion, viz., that of wiving the chihrs life, must be kept con- 
stantly in view, and since delay after rui)tureof the memhraues, 
if prolonged, is likely to destroy the child, it should be deliv- 
ered either by forceps or version as soon as dilatation of the 
o^ uteri and other existing conditious render such a proceeding 
sately prat^ticublo. 
3» 



434 TUE jyVLVTJOy OF PREMATURE LABOR. 



TrEATMEVT of PUEMATtTRE InFAXTS AFTER BrRTH. — 

The two ;;re(it dfttitlfntfa are vvaniilli ami (IkhI, u» wliirh a 
third nii>;ht be a<kletL viz., rtwt, Li»y the fhiM ujkmi a mass 
of. and (•over it with, coUoii wool. Kefp il near the tire, 
proterted from clianirea of temjHTiilure. liiunllt! it nirefully 
in wiLshiujr, tlte waU^r u-He<l heiu/ a:* warm na H)0'^ F. The 
mother'* luilk — (riven with a i«iMK»u if the child he too feelde 
to BUck, or dropited in the mtiuth with an "eye-dropper'* — 
nmst be udniiDiatered at fretpieut intervals, every hour, and 
without a lan^ fast <hirinjj tlie Tn^rht Shotdd the mother not 
have surtieient milk duriin: Hrst day or two, it mu?t be obtained 
from a wet nurse, or artiiioial fooil Iw sukHiitulod. 

The ehild'H skin if extremely delicate : henre it should have 
a 'biily bath (llMl^ F. ) not exeeeiUn^ three or four minutes in 
duration, and Ua napkiiiH inu.Ht l>e chauj^ed promptly, as soon 
a» soiled by discharKet* from the bbwlder or bowel. 

To maintain premature children at a uniform and elevated 
tempernture-. "incubator*" liave heeu employed, Tliese eon- 
aist of ohamben* with sufficient bre&thiui; !*|jace, in which the 
child lies, and the air of which ia kept at the dtt*ire<l lem]H'ra- 
ture (90'' to 1»8° F.) by artificial heat, supplieil by another 
chamber having hollow dou)ile wall* containing hot water 
aurroniidiu<; the interior compartment containini; the iufiint. 
The lid is of |;rla?3 throu^rh which the child may he seen, and 
the rtpparatuii contains conlrivances for rejrulalinir tem]»era- 
lure and ventilation nt will. "Tarnier's* incubator" and the 
"apparatus of Cre*U'" are now u»ed in many nutteniily hos- 
pitals. Tamier'i incubator ha« l)een much 8imp1iHe<t by 
Auvard, who?ie apjmratufl i« shown in Fig. 238, |Mipe 485. 

An incubator nuiy be improvised by placing lx>tlles uf hot 
water or hot bricks or flat irons iKMienth and around the cot- 
tim-wnol coutiiined in the ln)X nr bahket in whirh the child liee*. 
the hot Imtlles, ele., bein^ changwl fre<|uently. The success 
of this incubation-pnw'ct** rec^uirw* the constant attention of a 
nursp. and largely depetuls ufMtn the weight and prematurity 
of the child. Chiblren weighing lesf> than three pounds 
fleldom survive; of thoae weighing four or five ])ouud8 many 
survive. 

The proee«* of "f/aroi/f'*' — artificial introtluolion of food ioto 
the :^toinach — hn>4 also lieen employe<l in infant.^ too young 
id feeble to nurse, with apfiarent advantage A soft rublwr 



STERILIZBD GLTCE'RmE: UTERISE ISJECTIOSS. 435 

catheter with a f^uiall ^Xn^ Funnel at one end (»ee Fig. 239, 
page 430} ie moisteueJ, atui the free end passed to iho hack of 




A simple ininitMtur. (Aftvr ArVAtm) frt'm t>Hvl«. 
Jf. TTnt-water rans. K SInUt spntiK^. p. rhlUl's befl ; the arruvra show eurrenU 

of air. 

the ton^iio. \vhi<h prnvokes a reHex act <if Bwallowing, wheu 
the tul>e is (|uickl)' puslied oil duwu iiitu the Htoiiiach ; uow two. 



430 THE LXOUCl'ION OF riikMATUKE LABOU. 

three, or nion^ teufijKKmful^ ("an'onling to age) of the mother's 
milk, previously umtli; rwuly, are jxjureii into the iimnel, niid 
08 soon as it disappears by gravitation the tuhe is quickly 

Kiu. 2311. 




Tutwaiid ruuut!! furguviKC- 

withdniwii — there must be no waiting, or the child will vorait. 
AVilh practice and expertiu-jiw the whole pnx'ee<iiiig may ht 
done in fifteen set^ontU The child rest^ on the uur»e't< lap 
with its bead slightly raised during the operation. 



^^-^ ''"*.iM 



PLACEyTA PRjSVLL 



437 



ClIAPTKK XXIY. 



PLACENTA PR.^VIA 



HEMORRHAOE 
I.AKOR. 



REFORK AND DURING 



Placesta pr^^via couBists in impluuUUiou of the plat^nta 
aljorroally near to, or mure or los:* ovtT. the inienuil ns iiieri. 
There are three varieties: (1) TUe ImriJcr of the |)h(reutul 
disk muy i»e near the niurfjfin of the os without overlapjjing 
it, heuce ealled " mnnjhuii :" {2} the jtiacerita may he i^r- 
lialiyor(3) eonipietely over the os internum, hence, reHj>ee- 
tively, '' partial" or ^* compfett- '^ cases. 

Cannes, — Not eertaiuly known. Prol»aIile explanations are: 
Displacement of ovum from ili* nornml jK«iti<ui and lodjrnjent 
lower down, a.s after arrtvt of ttireatcne4l alK»rtion ; al)Mormally 
low jKK-<iii<iii of orilici* of Falloptiiii Itilies ; larjre relaxeil uteri 
of mu)ti|))irou>< women, in whicfi fohls of de<'idua vera do not 
retain ovniu near fundus when it tirnt entenj the wdiidi; hence 
the uudotihted i^reater freipiem y of placenta, pnevia in niulti- 
pnna It \a also more fre<pient in mulriple pre^^nancy. C'hronic 
eiuLimetrilii* is a predispcjsinj; canst*, and the same may be eaid 
of Tiiyoinata, carcinomata, and other diseases of the uterus. 

Contififiit^ucfsnf Phirenia Pra-ria, — I. Liability to premature 
labor; only alKtut one-third of the case« reach full term; 2. 
Tendency to nuilpreseiitjilion ; S. Fearful hemorrlia^e, j^eiier- 
ally comini^ on durinj; the hwt twelve weekit of pregnancy, or 
wheji hilnjr Ite^ns; the bUnMlirij? In^in*; earlier and greater 
according t^ the greater di»pree of placental encroachment 
over the oe; in the maruinnl caaes somclimet* not tintil 
"term ;" in complete oiu*. cxtrptitmally, bffore the last 
twelve weel»; 4. Death of the child, due to HHphyxia, to pre- 
mature delivery, or to heniorrliaire, or to conipnwion of cord 
durinjr version, or to prola|»He of cord and its insertion near 
nmr^rin of placenta ; 5. Liability to jiost-partal hemorrhage ; 
0. Danger of wptic infe<'tioii ; 7. Mi>rltid adhesion of pla- 
centa ; in premature cases the tisj*n4M'hanf:cs in the utero- 
pliiceiitnl junction, normally preparing for sejmnition at full 
term, have not yet taken place, hence AiK'alled morfrtW adhesion 
is admitted t*j exist in 411 jter wnt. of all ea^eii. Some say in 
a majority of the nvM«. 



3 



438 



PLACJSyTA PB^VJA. 



Sipnjitoms and Dlatjtiueie. — Bffnrr iabar aels in, placenta 
pncvitt is generally uusiisjjected uutil the sudflen occurrence 
of heiiiorrliiipe, which iH-jrine wUhuut nnu htonm caiMr, sorue- 
times even nt night during sleeji, or whilo urinnting in a 
chamber vcat^fl. It may stop ami again ri'cur. The (|unntily 
varies with the amouut ni' placental nfjunniiim (wliich always 
precedes the lilenling). Firnt attacks usually nioderatc ; ex- 
eeptiuuulty, <]uar(s of hloitd are h>t. and di'atli I'ojlowti one or 
two re<'urreiices ; such niscs are usually "comjtffU" ones. 
The quantity it; apt to increase with each recurrence. 

During lahor the hlecdiug liegint* early with conunencing 
dilntJitioD of the ob. It nu\y. in marginal caHei<, he arrested 
by rupture of meinbraut* and coiii*equeMt c<>nipres«iou of 
bleediug »*uH*ace by the presenting head. Liil>or jiaini' usually 
feeble, and dilatation slow. To lla^sH.* syniptonw must be added 
those due to blood-los:^ : riynco|vt'. rcHtle^oeHs, feeble pulse, cold 
extreniitieii, vertigo. iKMiduclK'-, etc. In fatal catted convulisiouH 
often prtH;*Mle death. 

The Jiofinfutin — clearly sns])ccl«l from history and Hyni|>- 
toms — ie i-onHmied by viiginal exuuiiiiatioo, the irregularly 
granular spontn* texture of the pluwutn being easily recog- 
nized by the liuger |NU«e<l into the oh. lu some priniipanc 
pHrtsing the linger to or through the intrrnal w may be difH- 
cull or inip<_w«ible : then, however, one nide of the lower wg- 
Dieut of the uterus may be felt, through tlu' vaginti, to l>e 
bt^grfy, mfl, and ruhircfei where the placenta in all«che<I ; an*! 
the pulj*ation of arteries may bt* felt in it. \ j^tethos^'oiw 
applirtl to cervix may revejil lond |(lacentji] nuirmnr. The 
sign ballotteiuent is obscured. DiagnuttiH cannot be poifUive 
until the pliu*euta i^ actually touebeil and re<^'ogDizeti by the 
eTtainining finger. During the first half of pregnaucy a i^eir- 
lain diagnosis is (Wp<issible. Uy skilful han<ls the 6|»ongy 
cushion of the placenUi may Ih? rwognized (chielly in bead 
presentatiotis) by nMmuifml /Hi/fitition. A region of the bard 
glolie of the bead feids olscured by the placental masn. while 
the part m»t n^vercd by the jilacenla retains its usual hfird- 
neaa. This can only occur when the placenta is tml i^ituatHl 
^toMfpriorly. 

Progmntitt. — Exlren>ely grave. Statistical eslinuitcs give 
niatenud mortality from '2it U) HO or even 40 |)er cent. Ab 
Btatislics cover a long periiMl of time, ne<*essarily s*i from pla- 



TREATMEST. 



439 



centa prsevia not (xrurriug more frequently than once in 
alM>iit \K){)\} Inhnr.s, ihcro is rcaMni to know that tlic above 
rate of morlalilv luu*; liuea rfduce<l hy nrtui iniprovfuienUs in 
treatment. Tlie (jutlmik w vvorfie in i)ri»ix)rtion Ui lh<* decree 
in which placenta overlaps the u&. Two out of ihree children 
are I»oru dead, and still othert* succumb soon ntWr lurtb. 

Treatment. — The main priiiriple of treatment is dffirery: 
there is no uafety for the women uutil the uteru» be emptied. 
It wa* formerly the custom, and still irf with ftinu' ub.KU!lri- 
ciaufi, when hemurrhajj:e occurs l>elore the twenlv-eij;hth week 
of pregnancy, to wait, oidy u»wg palliative nieasuret: to check 
lieiiiorrhaL^c, until the (Hiriod of Yial)ility, liefore attempting to 
deliver. This \a wron^{ and alway:^ unsafe. The child will 
seldom l>e «ave<i by tem|H>riziiig, ai»d the mother oi\eu dies 
with the recurrence of hemorrhage, iht bleeding coming on 
8mKleuly, a« it is apt to do, iji (be ab^nce of the jihy^ician. 
The lx!i8t rule ii" to dciin'r an jft/itn an practicable after the first 
occurrence of htuutrrha^t', whctht^r the child be viable or vol. 

The Ubual mode of delivery is podatic irrmou, |trefembly by 
the cond)iue<l internal and external manipulation — the so- 
calfcd ' bi|m!iir" method — and ful>sc(juent traction on tlie feet. 

While lhii« proceeilinp, fruni certain circunistauceg to be 
prest>ntly mentioned, i.s more fref|uently enijiloyed than others, 
it itf uut itJvHiifn advisable or {KtHiiibie. In t<e]ectin^ any metluxl 
for a 8i)ecial caj*e, the ]>articular <'onditions present must be 
firet fully considered. t.)ne of \\\et>e c*)udiliont?, of the greatest 
irnjjorlBnce, w the degree of dilutoHoa^ and di/atabHify, of the 
OS and rcrvij' uteri. If the os he not sufficiently o|>en to adnut 
one or two fin^^ers. mi methiHl of imnie<Iiale delivery is ptis- 
eible. Our main purpose now \s to rmdrul h'Uwrrlnnjc while 
waiting for the oh uteri to dilate, and aW* to ha>«tcn the dila- 
tation. 

The tampvti of iodoform gauze, iin*t plujrjiing the cervix 
uieH, and then the whole vaginal cjinal, provided it be 
securely applied, will crrtaiulij stop the blewling ten»|wrarily ; 
it also promotes dilatation and increases force of pain.^ ; or, if 
|jaini* be alwent, from labor not having begun, it will inaugu- 
rate theui. It should be rt*move<] in four hours, when the 
vngimi is to Ik' wa^hcHl out with an antiseptic solution, and o 
Burner's elastic water-bag introiluced into the 00 uteri (see 
page 430), which further dilutee the cervix and increases labor 



440 



PLACENTA PRMVIA. 



fuiins. Wlipii the iw wilj not ailuiit the ;j:ftuzt? tam]X)n — as 
may hap|K'n iti )iriMn;itMre t'u.-*e.s of |)nnni»ane — irnh may be 
first uschI tor (lilatiiti<in, or the iiihil(»r of Hepar may he cm- 
ployed. When i\\vi^ are mit at Laud, ami cannot Iw ohtuined 
without ^reat liehiy. the fiugrr may ho used to stretch open 
nml dilate the o» and cervix uteri. 

As »oon tii* the a** uteri is .suHieiently dihiUNl to admit one 
or two Hntrers, pofw tl»e whole Imnd into the vaLrina, inw?rt one 
or two fingers throujrh the os uteri, and \zBi ilowu one f«>ot hy 
Hick-s's hijK>hir version (dtwrihed fully in Chapter XIX., 
pfljres ^44-^47 J. l*nll tlown, sneeessively. the ie;:, thiirli, 
and hreeeli, which fill the os and et^rvix uteri, and act as a 
tHmjK.111 to Hto]) hieetlinp. Do not at once extract child, init 
let it come unaidei), or rtj**ist (»ccasiomilly. diiriuL*' paid?, hy 
gentle traction, so aj* to deliver in aliout au liour. With the 
child's lejr f<»r a tampon the diwicreeiiUle cotton plntf niay he 
diBpensr<t with. If the placenta l>e in the way, ]K?rforale the 
mendirane-H at its margin, or at any jwint where it may he 
wpnnittfl. Fnilinjr in this, plunjjc the fiiiLTcr tlirout,'h the 
placenta (theorjrnn is uHually tlutuier than in tioniial cws), 
an<l hrinj; down the \f"j throuLdi the opfninu; thus fnade. Of 
17H eases treale^l iti this maimer hy Di*:*. Ilofmeier, Belnn, 
and Ix)raer. in the Berlin Hospiial. the maternal mortnlity 
was i)u\y ftinr jmt cent., an<l the infant mortality sixty f»er 
ceuL — a remarkahly ptoil result 

Besides the means alreatly note*! to stop Meedin;? while 
wnitinff for dilatation, there remaiim to i»e amndered — 

Pnrdaf DitjUni Sej/arotion of the Pfftcfitln ( Barnes's method), 
wiiich Ciuisi^tt* in pa«(inp the hatnl into the nnjinu^ nud one or 
two Jiiifft'iA as far a** they will reach into the lUrnof. The 
finjrei^. then insinnaled hetweeii the plannila and the uterine 
wall, are .•'wept around in a circle so a.- to tinn//htf the srpara- 
lion of thtd imrf i»f the placentn attached near the cervix, and 
whi»st» f'/ieomplete ileiaclnnent kee|i«* the hleediiij: vessels ojien. 
It 18 often followe4i hy retraction of the cervix and cej<sjition 
of the hemorrhajxe, and in ej*jHH"ially «'rvieeal)le when the 
plni*ei)ta i.s placeiJ rntirchf over the os. Rapid expansion of 
the cervix with Barnes's <lilators and deliver)' hy version may 
follow, if desired ; or, there iK'inp no necettsily for active inter- 
ference (i r., no more hlwdin>r) the t^sc may complete itself 
without further a^istanee. 



PARTfAf. DIGITAL SEPAHATfON OF PLACENTA. 441 



Nearly ullied io Barnes's inetlnxl is tliat ol' Coltni and Davis, 
viz. : Paws one or two fingers in between the pliu^euta and 
uterine wull, ou thnt side where ihe s(*puratiori huH iK'giiu. ur 
where the attaehment is least eitensive ; complete the »epara- 
tum nti ihii* *iiile, and then let the tinkers hw»k <l(twn the 
bonier of thit* lixwjened Hap of placenta ami park it dnsely 
a;rain.«t the other side of* the rervix. Tlien rupture niem- 
branes, ^nveergoL, and hasten ilclivery. Should pains I>e strong 
with the liead presf ^tin;.^ the latter may enirnue within the oa, 
and, by iln p^eM^urt• against that !*ide from vhich the phuvnial 
Hap wiw removed, plug ihe vessels and yti>p Ideedinji;. Should 
the paiuH tiot be Htnm^ enuutrh to force duwu the head in this 
manner, a foot may l»e brought down by version, and thus 
the lej; and bree<*b l>e nia4le to act arf a plug, as in the Berlin 
pr(xe*^litig belbre nieiitionetl. Even though the presenting 
|Mirt <li* not ent*.T and art a* a ]»lug afler thi^ one-»ided arti- 
fifial separation of the plueenta, the blee<ling vewsels have a 
chanee to retract and cl(»*e llieir oritiei-s, for they are no longer 
on tlie stroteli ; moreover, the transverfle bri*lge of plaeentn 
which inij»e<le8 tlilntatioii, k^itig now free on one «di% uu 
longer im|)eilefl it in this way. 

In cni'ieH where, iH-sides lM»ing inidihited. the os is rigid and 
the cervix long and rigid alw, we again resort to the vaginal 
tnmf)on atid Barnes's dilntors iiniil the <f rviral tisHuei* l»e<\>me 
snfHciently o|ffn and H>ti to admil the linger for ilie execution 
of version or pndial «epnnilion as befure oxpIiiir»e<L 

Iii)N>lar version can l>e ilouc whni llie os is as Amall as a 
silver /la/^VIollar, or even less, fur the tissues of the n'rvix, in 
most eases, are unusually dilatubh* in ]>latvnla pnevia, and in 
many C4is4»s the child is smidl. being premature. High nuthor- 
iticB advise to pnM^eeii l»oldly with thHiy-n/ when tlie vxtmnil 
OS \» the size of a silver half'-*lollar. for the cervix and luOnuil 
(jp ore still larger nnd strcirh uilli great f:i<'ililv. 

In trnnsverse pres4'ntations — n<H infrwpiently aRWKnated 
witfi i^lacenta pncvia — jwdalic ver-ion by i-xterinil or bi|«>lnr 
manipulation should l>e nrcf>mplislic<i iM-ibre membranes are 
ruptureii or ergot given. 

lu cases with hemorrhage, liefore lalM)r Ivgiiui, theililalura 
and tam[K>n. used to stop blee^ling, will excite pains and bring 
on labor. 

In a renjfeiv casea (usually multijmne at or near full term) 



442 



PLACEST.i PR.^VIA. 



when tlie o» is preUy well dllaied. and llie placenta pra-via is 
only imrtial, and pains are st^>n^^ siuiplo rupture ot'tlit niem- 
Uniiics may Iw* all that is nM-i-ssary tn sinp lieimirrliagc, and 
tlie lulKtr will profvtrd by itetdl'. or (in bead presentatiuii / l»e 
ex|WMiited, if neeessary, by (orwps. Sboubl the [uiins he inef- 
fieioht, er^^ot riiuv \w. ffiveu, and manual pressure made u|h>u 
the up|>er end oC the t'tetal (>voi<l over the f'undnH uteri, (tr the 
liaud nuiy ;:^a^p the head id" the ebild luw duwiu over the 
lower part ot* tlie alNlunien. and thus nstiist its deseent into Uie 
pelvis. In no cum*, (»i' course, tdiouhl ergot be given, or the 
membranes l>e ruptured, where a subsequent version is to be 
dune. The eas*e^ here referred to are those in which it is evi- 
dent the heniorrhuge may be controlled and the child delivered 
u^UUtud version. 

The UPC of ergot in placenta pnevia early iu labor is not 
obje<iioiiablo, jis in ordinary labors, because iu nu\st cases the 
child Lm «imilL iK'iiig prtnnnlure, liefore uisinj^ it, however, it 
should always l)e ni5<'ertaine<l lliat there exists no oih^r mei*ban* 
ical oltfctructiun. sneh us transverse presentation, |M'lvic luir- 
rowiug, tnnioiv, etc. Shnubl llie prejrnancy Ik* at term and 
the cliild ;*m// tt'netl. the use of ergot is not s** safe, yet the risk 
in using it even here may be leiss than the dangers of tielay 
from inetlicii'ut pains. 

Simpson's niethiHi of treating placenta pra>via consisted in 
completely scitarating and extnn ting the jtlBcenta, trusting to 
|K»wcrful uterine conlrnction for sulfSi'ipicnt rapid delivery of 
the child — a trust so seldom reali/e<l in practice that 8imp- 
mn'fy plan s^-nrcely allows a chance fi>r the child's life. Com- 
plete scfHiralion i>f the placenta, however, will oilen arrest the 
hemorrhage, and may. therefore, be of use wlieu the child is 
dead, or liot viable, or pretty sure t*) die tVom prematurity of 
the labor ; or when great exhaustion on the part of the woman, 
and the state of her [lelvis and soi^ parts, conlra-indicate 
delivery by version. 

Ana'nnn, sv^ncope. ur(*ollaiM^. frcmi li>ss of bl(N>d, will retjuire 
siiniubnls, etc., as more particularly de»*cril>ed under post- 
parial hemorrhage, in the next chapter. 

No preci«' rules can be laid down for the exact treatment 
of placenta prxvia in every case. The nmin dirticulties. dan- 
gers, un<l priiiciph* of management having IhH'U Icarneil and 
the serenil methods of treatment enumerated, the rest must 



HEMOHEUAaE BEFORE DELIVERY, 



443 



dcpieiid upi)n thi* judgment, skill, and sclf-poffioBirion of the 
mxrouc'heiir. 

After di'livery erfjot must \m> ^iveii, and for st^vcrnl days, to 
prtjveiit |KWt-|KirUil lK*morrli»L'i* ; and a two \>vv cenU ^flutiou 
of (rrejHu should l)« iujeiHed into the vujrinu twice u day to 
prevent neplic irdWiJdu, Should hlcvdinj: n^cur. from the low 
se^inout of the iitenii*, whtMi tlii^ IkkIv ot* iho orpin is well 
coiitnirted, thf lih'ediiijr surtiu'e miiy he swahl>e*l with ii solu- 
tion of :^ty)>tic iruii. throujj:h a ^(lecutum, or tuuijKnivil with 
iodoform gauze. 

Hemohriiaoe bkpork Di:r.ivERY, ittrr wiTnot^T Pla- 
centa Pk.evia. — I'urlial separation of the placenta, with 
bemorrhaife, may Of-cur during the latter months of preg- 
nancy or after Uil>or has hegun, when the organ is uormaUy 
titattted. It may reftult from blowr*. falls, or other n)eclmniojil 
violence; jjathidogicnl degeneration of llie placenta or utero- 
placental juiuiiou ; profound an:eniia. ulhumiiiuria, and niul- 
tiparily with fre<^[uent child-hearing are prnhaUlc pretlisjiOHing 
euusoj*. It .HiHuetimet* rer*ult<i from nejihriti^j ciuring pregnancy, 
ns well i\:* t'nnw other acute di?k'4if*es. viz., variola, jHsirlatina, 
typhoid fever, and ucute yellow atrophy of the liver. Seldom 
oix'urn in primi|>ane. 

ASifiufitonis. — Flow of blood from the uterus; purr blood 
when it e(.»nie(* fn.iin lietween uterine wall anil urdiroken meni- 
brancH ; \)Uhh\ mi xai with li<)Uor amnii when liie niend>mne0 
are broken. Ilcniurrhagc {coupled with alarming t;yneo|)e), 
distention and irregular bulging of the uterine wall ; laln^r 
ym'iu^ may Im alteent alttigethor. or, if prownt are irregular, 
fe«hte, and inefficient. The i'(>lhip}ie, pain, etc., o<vurriMg 
during labor have Uvn mintaken fur rupture of the uterus. 
The latter, however, will \\e accompanied with re<ef*iion or 
nmbiliiy of the prcwnling |mrt^ and entuijie of the child, wholly 
or partially, into the al>*lomiinil cavity. Uupture is usually 
preceded by rxnfnti uterine contrnctiouH. 

PiiHjutma. — Kxtremely grave. eHpwially in conceah*d niwa, 
where the diagnosis is, or nuiy be, uncertain, ami efti«'ient 
treatment |H»st|M)iie4l. The malerruil deaih-rale is, rfjugldv, 
aliotit .'»0 p<'r cent.; the iidiml mortality, !»•'» |»er <**!nt. Luckily 
this accident is not u conmion oc< urrence, tliough it is, per- 
haps, sometiuiefl uudiacuvered. 



444 



POST'PA n TA L HHMORRHA OE. 



TmtJbnmL — Stinuiliilt' uUiriur routracilon ttnd bastea 
deliver}' by every pmptT jiviiiluble nieniui. As a rule, the 
iiiembrane** miiy l»e ru|iiureil and llie uteriif* coinpresined from 
till* ouU^ide liy u Hnn iilHiotiiiual hinder. Tlii^ will mtmHimes 
stofi \\\v h*'n»i>rrh:ijre. It' not, pmoee^l to dilate* the cervix arti- 
Hnully» lind deliver by tbreejirf or version. Intenml versiou 
will i>u ustiaUy ue<*e-'wary after waters are evacuated. Avoid 
lilt' vajrinal tainiMJU ; tlie »ourt*e of bleeding; it* ^>o liitjh in the 
uteriij* lor plumping to lie n\' any u^ ; it would simply i*ause 
blooii U) lie cx)n|;euled in the uterine cnvity and inrrc!i»e its 
diiiitention. After delivery of the [dacenta, nhould hemorrhage 
coutiuiie, the oterinc raritij can lie firndy imcke«i with taiiipoa 
of i(Mloforni gauze, lu* in any other time of ]Kj8l-puxtum 
bleeding. 

In caM7« of delay, from lack of eerviml dilntation, it baa 
l»»»en lately sup^ested to do an abdominal peolion- — a Potto- 
t';i«areiui si-ctiou — this beiritr lessduntferous to the woman than 
contiiiueil heniorrlui^'e wldle waiting tin^e waitinj^r lor dilatation. 

When the child is dead, craniotomy may l)e doue iu any 
ejiM where it would ex|>e<lite delivery. 

For the treatment of coll!»|)s*', eto„ following hemorrhage 
after lal>or, see the next rhiipler (pHj^er' 4ol-4.!>3). 



* 



CHAPTER XXV. 

P08T-PARTAT, XIEMORRIIAdK — ** KLOODIXG." 

Hemorritaok after delivery of the rhihl^ and either before 
or after delivery of the phcertta^* is a m<y»t ihinperous compli- 
CHlion, Hometiiiu*H eauKini; death in a few minuleH, ee|»eoiAlly 
when unpre|»i»red for and irn-wtlulely managed. Hwice, 
n(tvi*Mly nt' tixed princi|iles and decidwl remwlies, uskmI with- 
out hcHitJiiion, in (he hour of m*ed. Dr. (Jooch well r*»id : 



' nic term* " jwi-piiftvm nr pmi-jmrtiW—inny «'oni to bp, rtrictly i^iM'ttklng, 
limiiplirAlilr tui'Mfr-i In wMoh \nv fifnrnif; •. */.7 „u>l,hi-,r>.i. r.r t(.. tlilr.l rlan 
of Ijiiinr Ik not yt'ln\rf- linti i' II Ik II' 1 ike 



ihK <Untinrt[on 'I'Ih-h' i- norvitl ui 
be iIl'UdciI ok iiftvr rfiiiit-Nrtfi inihI It 
KUlntMl ploMliU. 



ith 



RETE'STIOy OF PLACENTA. 



445 



"No phyaician should have the iieHurance or hardihood to 
cnjss the tlire^lnild of a lyinp-in <'haml)er who is not thor- 
oufrhly loiivcrHiint with thr n'im'tlii*s fitr fltuMlirifr." If. con- 
hist> of hitrfiiu^ from the n\Kru mouth:; i»I' uleriue hlwui rhan- 
lU'lrt fnmi whicli Hu* [ilaivutji hiw, >\ holly or in |>arl, heeii 

t'liKHftt. — CWret'lly appreciaiiug the causes of flnodiitg por- 
mita prt^reiition, whifh is hclUT than rure. Kxt'hidiiip, fur 
the ])resent, the rarer CLse-s iu \vhiel» Ijlecnling occurs froui 
1m*erntion of thp uterus, vajriua, nnd vulvn, the one condilioii, 
ahove all otlierH, that leiuitt to HixMlinjr is (frjirieut ufn-inr row 
trttcfion — HLUMoliinei* a iotof wniw of it — inertia titrri. Why 
should the witndi remain itu'rl aUer the child it* lioru? lis 
n»ut«'ular walls may Ite \\(»rii out l>v a /oiiff /afxjr ; or partially 
paralyzed, like au overi'ull liladdL-r, from previous ovtrdii*- 
tent'ton due to amiiiotie drc»|e<y, or plural pre*fuaney, etc. 
T<:h> rapiff hfmr, a.s hy injudicious hn.ste in artilicial delivery, 
or from ahuormnlly enlar^'ed pelvic e?*[>e<i»lly when preceedeil 
hy overdisileution of the wotnli, producen it. The uterine mu»- 
cular wall may he congenitully drjivifiit in (inehprncut (Hfi iu 
precocious mother}, or violfnrwtfi, or hound down on the out- 
side by fferitoncfil otihcsious, *»r tfjrhii'fil/iitlrijfmntfnl i'roni pre- 
vious iullammation. or numt'ioiiK ainl tiulcfcftf .iurrfjiMtr hf>oi% 
fiH in elderly women. Weak uterine niuscles may occur from 
fjnteraf ivrahiffjn of lliv uvman. due Ut con^tituliouHl dit»eaw.'. 
severe previous illness, exhauHiing disi'harge**, heal of climate. 
eU\ 

Diftteiition of hhtidn- or rrrivm causes atymjnttheiic uterine 
inertia, as may also riot^vt viminl rmotiou. 

Jti'fention of pla/'ftita — whether from morbid adhesion, larjre 
eiJie i»f the orpin, or irrejrular { *' hour-;rlass '*J c^outraction of 
the nornl) — mrrb'nntitffu prevents cluw naitractile approxinm- 
lion of the ut<»rine walls. In llie ciise of niorhid jilacental 
adhesion, the jttirtiafhf HrpttniUtI hl<MMl-<liaiMK'ls are k^'pt open 
and rttnuot nirnrt to prevent hlcciliuL'', a.-* lliey normally should 
do. It is liahle to o<*eur, as alreaily stated, in placentii pra*via. 
A short or coile<l funis may lend to separation uf tlie jdacenta 
l»efore birth of the child. The plaivnla follows the delivery 
of the child almwt at once, and with it comes, sometime*, a pn> 
fuse beniorrhaLT*' — MimhI that had accumulatinl in the ntiTue 
between tliu lime of jdaceutal »e|)aralion and delivery, Occa- 



446 



POSTPARTAL HEMORRHAGE, 



ally fibroifl tumor of the uterua, when senteJ near placeotal 

will |in>*iiiro i»:inf)rrhn;.'c'. 

Tliiwi' whw have lloydtMl in previous laliorp are apt to flood 
a;^aia. Thin is ol>nerve<i in |iU'iln»ri<- women, suhject to |m*f*iii<e 
mtMiistruaiion, and is turlhiT explicahle by exit^tcuciMift'oudi- 
lions as to [n-lvi-s wonih, etc., previouidy meutiuDefl, wiiich axe 
I)erriuinent and irremovable. 

Further cAUKea are : eonditiong whieh iiiterfere with forma^ 
lion of, or which teinl to move ami ilisplat-e, i-oagula in the 
iDOiiths of the hleedinjr veswls. The bloo»J-t'han).'e? of iiro- 
fouuil albiiiniuuria, ami wastiujr ^li^*'4lik•^, }>i«sibly the soejiilod 
** hem(»rrha;:ir <liHlbe.-is." may reiani fi>rumtion uf eoagula ; 
and formed or hulf-fornied clola may be displaced by strong 
arterial tenKion and pulsation, or by the patient suddealy 
risin<!^, '*suee/in»:, ct)iijrhinjr, laughing, vomiting/' ete. tLusk.) 

On the whole, the one main cjiuse is deficirut tttrntie rontrac- 
tinn. When a coutraeteii womb continues to bleevl there is 
prolwibly laceration. 

SifrnptoniA. — XTiiwhingof bl(M>d fn»m tlie vaginn. either imme- 
diately i>r some time atWr l)irth of the child, or still later alter 
delivery of plaeeniji. Quantity variable: moderate or fatal 
— a trickle or a fl(HMi. AWnw. partial or complete^ of hard 
uterine plolie on hy])Oiriii*tric palpation. Tlie womb may l>e 
Hol^ and greatly enlarged from airumubuiou of bloiKl iu its 
cavity, with little or do extt^rnal tlow ("concealed hemor- 
rhage "). in either vane there are fiymptoniH of bbxnl-loai: 
deathly |»allor; cohl extremities; feeble, frefpient, thready, or 
imperceptible pulse ; gaping. re:*tIesHne«s, dyapnti-a, and hunger 
for air; thirst, and eveti hunger for i'i>w\. lu tlie worst cn^ea 
8ynco|>e, loss of vision, convulsion, death. 

TrentnifiU. — Prrwritirr nntl PirjHinihrif MranurcK — The 
ne<"essity of guarding airainsl relaxiitimi of the uteru.*? and 
prf>moling uterine c^mtraction during the third, and near the 
end of the second fdage of labor — by manual pressure — htis 
already iM^en iu.siatcd ujwn iis a j)recauti(m in every caflB. 
Every ol>8tetneian should prepare for tlooding 4luring eecoud 
staire of lalior — whether it Ik* likt-ly to oc< iir or not — by pro- 
viding iH-'forehand a i;o(Ml-working I)avid»»n flyringe, ico ia 
piec*«s ihe si/r of an rgij. bramly. sulphnri*' ether, neutnd |»er- 
ehloride of iron, carlHdir iu'id, ergot, a .dilution of morphia, a 
can of iodoform gau^e, a hy[ju<]crmic syringe Hlle«l with Huid 




TREATMES1\ ETC. 



44? 



extract of ergut, or two graiDS of ei^otio in solution, tog'ether 
with pifrhf re of hut and toM wiiter. au empty hasiii, a founUiin 
svritiije, and a l)e<i-pun, all plat-ed within ejusy reach of the he<J- 
side; a preparution ni'ither t«dii>u8 nor troublei$om«, but which 
may «ive a life. 

When the henuirrhage oceiira, grasp the uteru«, without a 
mouunt'ft (fef'ttj, ihrotigh the aitdoujiiml wall, and kuead it with 
the Hnger-ends. to Heeiire t'ontraetion, while an npsistant injeeta, 
hypodermically, a drachm of Huid extract of ergot, or two 
Rrairifl of ergntiii in a drachm of water into the outside of the 
thigh, Ivet the nurse give a <loBe of ergot by Ihe mouth, aud 
also put the child to the lireaat. Witli pro|)er previous prepa- 
ration utid si^lf-iioHsosioa, all tills can have been done within 
thirty seconda. 

Sliould the womb not yet wmtnict and the flooding continue, 
let one baud continue to gnisp the fundu.s uteri on the outi5i<le, 
while the other f again without het^itation) ie |>m»ed quickly^ 
but geutly, into the vagina aud ut^^rufi. (The huudfi inut«t, of 
course, be renderetl ajfcpttcuih/ clean. ) Now the uterine wall 
i« In^tween the two hands, and may l»o pn^s^^l bolwc<?n them, 
while the outride one applies friction to the fundus : or, again, 
the hand in.-iidc may l)e gently twijuted round at) a.« to irritJite 
tile womb aud pnHju<'e coutractiou. //' the phiveuh hr muh- 
iiirrrd, it must be reuioveil at once, either by gru.spiug and 
wiueezing the tuuiiuB iirnily by the outside band, or the hand 
inside grasjis the plac<?nta iMxIily, having previounly eepurated 
any remaining adhc«iouR. and gently withdraws it, the baud 
outside meanwhile compressing the uterus with sutbcient firm- 
nesa to mpiecze its anterior ao«l [wnsterior wall? together. If 
the ftiacrnta br drtit^red Wtore the tlfMniing, and large blood- 
rlols oi^cupy the cavity, these must be fearlessly reniove<l, antl 
the ol)Kletncian'0 bantl take their [ibice. A H|>ecial mode of 
grasping the uter\is — bimanual manipulation — may be trietl aa 
followrt: Prew the tingcr*endH of the outside hand deep in be- 
tween the umbilicus and uterus, so iftat the bitter res-ling in the 
palm may lie pu.'ihed down aud forward against the puliee, 
while the other hand (or two fingers of it), [mesed high up 
abuig the jMWterior vaginal wall, presses the lower segment of 
the wond> — in facU it« cervix — forward toward the bymphyKis 
pubis ; thus by a mtri of teni[M>rary anteflexion the canal of the 
neck is closed aud uo ItltHMl cau come out, while the pritisure 



448 



POST-PARTAL JiEMOHRUAGE, 



above preveuts erjlnr^emeut of oaviiy and accumulation 
witbiii. It alKi atiiuuiatw* routracliuu. (See Fig. 240.) 

A perleetly clean iifie|jtit.* sjwiijt^e, or, pretenibly, a similarly 
^•lean bit uf rag or i^iuail [KKket-iiauUkerchier, butunitwi with 
spirit of turpentine, or whiskey, paits**! into ihe womb, and 
bquee/ed so tbat the tipirit coujets in couiucL with ihe uterine 
walls*, are eltieient stimuli to uterine eoutraetiou. A doth 
cunluining pure rhlorotbnn, [kai^i^Ml into tlic uteruH and allowed 
to remain tiiere for a time, has uleo been used gucceesfully. 



Fuj. :i4a. 





Blnuoual compreMlon (iroduciitg HiiU'nezIon.etc. 



The old — but well-t(^sted — renuMlien, of n rolled |/nshed lemon 
and a t*|x»nfre filled with vinegar, being intnMJiiced and wjueezed 
while iu the uterine nivity, have of late been objet1e<l to nsj 
being asepticnlly unolean. They are, however, powerful ex- 
citants of uterine eontraetion. The vinegar ean be sterilized 
by boiling, and, in ras>es of emergency, it is usually obtainable 
in ever\' honsohcdd. A lemon can be rendered aseptic, on its 
exterior, by immersion in a bichloride solution, and that septic 
genus inhabit its interior structure is at least improbable and 
certainlv not demonstrated. 



b 



TREATMEST, ETC. 



449 



Ooe of the lieet ioteniRl m«iLcMl« for arre^liDg ihis henior- 
rfange w irrigation of iho uttrine cavity with hot siprilizfti 
water (115*^ to 120'^ F. ) by meiiiis of a Davitlsou or fotiutaiu 
8yrii»we, care Ix-iiij; (nketi that the nozzle uf the instrument is 
fi'ce from pcnns and its titlw completely emptiwl of air before 
being ui*e<l ; a I)e*l-pan rnt'eives the returning water. 

Jn every ctirM? the chiUl, whether washed or not, may bo put 
to the l»re«-"'t, by an asfiistJint, in the hope that tfuctiou of the 
uijiple-H win province retlex uterine contnu^tion. 

Coiitniutiou tuay Bouieliines be imhiced by rc»lling a pieoe 
of ice on the alxlonieu over the fimdus at intervals, or pouring 
euld water from a height u|H)n il, or Happing it with a wet 
towel. 

Of late years a safe and efficient method of arresting hem- 
orrhage haa l>een found in the uterine tampon of iwloform- 
gauze, or of gauze soaked in a 3 per cent creolin mixture. 
Kenieniber, it is a tampon iu the nteriuiy not iu the vagina. 
The gauze is soaked in a 20 ]>er cent iodoform solution and 
sprinkleil with iodoform powder. Three stripe of gauze each 
2 inches wide aud 3 yards long are prepared. After disin- 
fecting the vagina with a 2 per rent creolin solution, or with 
a 1 to 3()(>0 soiutiou of corrosive sublimateT the patient is place<l 
crosswise on the edge of the l>ed. aud the tara|K)n introducetl, 
by seizing the cervix uteri with the hooka of a volsella force|j8 
and pulling it down to the vulva, wtiile one end of the gauze 
strip Ls grasfKMl by a |>air of hmg uterine force|)8 aud carried 
to the J'ti^i/iu*, then the foreejis are withdrawn and another and 
another fold of the strip intrmlnced until the womb be fillefl 
— completely and finnlif filled from fundus lo external as. 
When the genital jMuwage and vagina are large, so that there 
is plenty of room, the womb may W puslinl down by pressure 
of the letl hand over the fundus until the os [»e<X)me visible iit 
the vulva, when two fingers of the riglit hand puph up the 
gauze into the uterine cavity until it l>e full. The rough gauze 
is thought to province irritation of the uterine muw'les. and 
hence mutraclion. The tampon may remain twenty-four 
hours, when it is easily remove<l by trnction on oue end of the 
8trip. The advoi-aiw nf this methoti 4'onsider it su sure, safe, 
nutl simple that iuHteiul of nuiking it h hist resort, they use it at 
ouee, if ergot ami nuinual coniprcrtsinn fail tn arrest the bleeding. 

Under no circunujtaiices should a vtujimil tJun[xjD be use<L 

29 



450 



rOST-PARTAL HEMORRHAGE. 



It woul<! ortUH*? llie uncoiitnictt^l oiu}»tv womb to fill up with 
liluo<l, thus t'oiivtrliuj: tiu external lifniurrhii;;*? \uU\ iiu inter- 
nal, "conrenlotl " oa(% aud eulargtug iu^tead of dimiuiBhiug 
thi' uterine cavity. 

Ah ft Iant rtf*<)rt wheu other nieaus fail, the uteriue cavity 
niay Ix- injooteil, in- simply swuhlied nut, >Yilh liq. trrri per- 
cblor. for liq, fer. persnlph. ) one |mrt to five parts of water. 
TMb eousrriuges the months of the Ideediug vessels, coagnlales 
the hloud in iheiu, and Btimulat*^ uterine coutraetioD. The 
remedy is not without tlanger to life, hut is justifiable when 
(fther lueuns have failed. Tincture of iodine, one part to three 
of water, has been used in llie sarne manner. 

r)r. Rarncs insists that the duii^rcrs of injecting uterus with 
styptic \nm Hilution will lie preventwl if the following rules 
l)e followed in uning il : (1) he siir« that uterus is empty of 
plaeentji* blmxl, and clots ; (2) compress body of uteruH during 
injection* with the hand; (8) have two ba^Hns ready, one con- 
taining hot water (with which womb is first washed out), and 
another containing the iron-solution (which iiumeiliately fol- 
lows the hot water). Injeti seven or eight nuriccs of the iron 
solution, ah»wly and gently, all the time keeping up 8tefuly 
pressure on fundus uteri. Dr. liarnes's formuljp are as follows : 

B.^-Solid ferric chloride, 5j, 

Water, gx. — M. 
or 

B. — Liq. fJprri perehlor. fortior (Ph. Br.), "^m. 

Aquae, Jviiiw*. — M. 

He ndvie**s womb to I>ewashe4l out daily with carbolic iujoc- 
tionfi aJU^rwanl, to prevent septic:cinia, 

Corapresfiion of the abdominal aorta has been employed 
with good results as a teDi|X)rary measure in urgent cases. It 
cuts off the blfKHi-flupply to the Hooding uterus, stimulates 
uteriue «>utraction, and ie^eens risk of fatal syncoi^" Viy keep- 
ing blood In the brain that would otherwise How downward. 

It has been rei'cntly recommended, iKirticularly in (raaefl 
"where the bleetling results from large arterial vtiSK-ls that 
have undergone atheromatous <legenerulion." to o|Kni the al»- 
domcu and remove the uteritu by supra-vaginal amputation ; a 
mcthoil that few ol»stetrii-i»ns in private practice would will- 



lb 



TREATMENT, ETC, 



461 



ingly undertake, and that Btill fewer women, exhausted by 
previous hemorrhapt^, would he able to survive. 

Anotlier rereiit sugjre.«tion in to invert the uterus completely 
tlirouirli the viijrina. emirclv it near the iitrk with a rubber 
tutM.' or baudiitre uf i^Kioform gutize, aud thus arrest bleed- 
ing. Atler sis hours, llie IuIm? (or bandage) is removed, and, 
there being no recurrence of heniorrhage, the inverted uterus 
ifl rophu'ed. Praetiee has not yet demouslrated the utility of 
thi* oftcration. 

To epitomize the most useful, and meet available remedies 
and the order of their tuccescion, we may my,jiriit : External 
and iiiteruul manipulation, erjrol, and putting child to brea»t ; 
nerottif, irriirutiiin of uteriue oivity with hot ( 120° F.) sterilized 
water; //nVt/, tirui utertTie tampon of iodoform gauze. 

In every caw when tlio blwding has been arrested and good 
contraction of the uterus produced, the organ niui»t Ite sup- 
ported on the outside by hrui and equable coniprt*ii*ioti over 
tite uiHJumen. in order to maintuiu its retniction and prevent 
recurrence of hemorrhage. A we!l-adjuv*led abdominal iHtider, 
with cninpn'Si*es over the top and >)iiU*s of the uterus, should 
be carefully applied. Prof. Lusk huggest* a sack partially 
tilled with moistened sand or conunon salt as a reliable com- 
prrs?< and easy to obtain. A snudl basin, padded iuside with 
napkins, phiced over the fundus, is another siniihir device. 

in all eases it should be asi*ertaiued that inertia of the 
Womb is kept u[) by a full bladder or rectum. 

To restore the circulation atler hemorrhage has ceased, or 
to prevent im|>ending fatal syncope during its continuance, 
8liinnlaiilj!i, tiutripnt;^, and ojiuiles are required. A drachm of 
]»r;uidy. wliisUcy, or sulphuric ether may be giveu hy|H>der- 
mically, and repeated at re<juircd intervals; or strychnia 
gr. ^^^, or nitrtvglycerine gr. yln", morphia by|K>dermically to 
]>romote cerebnd congestion, and tinruire of opium and brandy 
intenmlly in full dixiies, together with plrong UvA' esHfncr, milk, 
etc.. at short intervals. In fee<ling the patient, the smallest 
qtiajitltij — only a tenHiK>onfid every one or two minuti« — may 
be nil the stomach will bear without vomiting; this to be in- 
creased as larger jwrtions are tolerate^l. If, in spite of care, 
vomiting occur, opiat<«, sliniulating and nutrient enemata, or 
livi^idtTinic iiii«'<'lioiis nuiv !►*' uscil, to the t*'ni|>orary exclu- 
sion uf moulh-fccding. Admit plenty of fresh air from open 



452 



rOST-PARTAL JIKMORRBAOE. 



windowB. Uemnve nil jnllows. to keep the head low, and 
elevate the loot of thf hwl. thun promoting ^nivitulioa of 
hlom) to tlio hrain and Tiuvlulhi. Tlte hend iniiFt n(»t In? niiseil 
from \u depomleut [wsilion, to give foo<] or n»e<linne, nor for 
any other purpose, for fear of syncoj^ and fatal hcart-cht, 
until reuctioti Uuve taken ])lu(*e. 

Coinpre^jsion iif \\w brarhial ami femora! arteries — or bind- 
ing the four exlretuitien with E.«ninrrh'n bandages — like aortic 
comprfA-tiou — may keep enoULrii IiIimmI iu the hrain, tempo- 
rurily, to prevent death, while stimulanls ^et time to aet. 

When death i.s nai near :it hand tliat respiration >H*en»s alwnt 
to cease, flick the face, neck, and hreaei with a wet, cold 
napkin ; it iiivoket> additional inspirations, and is UBually 
grateful to tlie i>atieat. 

When stiinulantd and the other measures nieutione<l, fail to 
proluce reaction, Iransfu.siou may save the patient. The 
transfusion of hhwMl. or of fresh cow's milk, formerly ueed, 
have of late Uxni sujjerscded \^\ the more ea^jily available 
proceeding of infusing into the circulation a saline t»oluiion. 
Ah nnieh as a quart of the following mixture may be slowly 
introduced into a vein : 



R. — iSodii chloridi, ."sytw. 
StMlii bicarh., pr. xv. 
\i\. destillat.. Oij. — M. 

Dr. Lusk nras a simple solution of common salt, five graina 
only to a pint of water. The fluid mny !►€ |>asseil into a vein 
of the arm — Urtunlly tJie mwlian cejihalic — by means of an 
elevated fumiel. or tountain syringe, from which dcfienda a 
tube surmounted at its lower end by a small canula for pene- 
trating the o|)eue<l vein. 

The following sdmjde methiKi of ar/ma/ infusion * hofl been 
successfully employed : The saline solution having lieen pre- 
jttiretl and plat*ed in a fotintain syringe, the needle of an 
ordinary hyiiodermic syringe is slowly plungeil into the tisBues 
of the thigh until its jx^int |>enetrute the fenmral artery 
(indicated by the rtp|>earance of arterial blrHxl in the nee<l]e), 
when the end of the rubber tube is fitted over the base of the 
neetlle and securely tied by an assistmit, who then holds the 
> Tills U Uiti mflhiMl uf br. It. U. P. Unwbikni. 



SEc^SDAny vosTPAniwh in:MoiuiiiAaE. 453 



BOedk' immovalily ; or, in the uliK^ire of :i)i ns.»)i!it;int, the 
needle may l»c jrrus|HHi liy n jmir of lui'iiiuNtiilir ((»rc*'[id, tlie 
lminUfy iii' the Intler Iteiiijr lluni lixe«! mi (lie (lii*:h with r^trii* 
ol' miliejstve pbuster The laij? of the t'ountjiin fivriiige o>n- 
Uiiuiiig the tt»luLiun may now be elevalwl fix ur Beveu leet 
alK>ve the level of the thi^b. when tlie fluid rflowly tlows into 
the artery hy grnvitnlion. 

Whal^^'er methoi) in used, the soliitiuii must always he hot 
— about 100° F. Half :ni hour or nmre ruay be reipiireii lo 
allow the gradual iutroduelion of a sutfieieut quuutity of the 
Hui.i 

The fiw]Jiiii fitui hf»i method of re|deui.«hing the depleted 
bloo<lvea*eli- aud restoriujr the cireulatiun (far safer thau traas- 
fusion into an arten.' or vein), i-s to inject larjire fpiantities of 
the I'aliue s<»lution hy|»odertuieally iuto the eellular tihsue, 
eitiier in front 4it' the ehest, or l)ebind tielween the eeapulre or 
iuto the uutesi. Two or three, (jiuta of "normal silt solutiou" 
( /. f., three jrraiuH of coummn wdt to the ounce of wuler — 
approximately I(K) prnius, or a t*niiill teiispo<juful, lo water 
one<pnirt ) is ])reparetl (the water liaviuir lieeu previo»:sly steril- 
iwd liy liniliugt and j)la<'ed in a fountain i*yrinjrc, the tulie of 
wliieh is sunnoiinteil with a lar^^e hy|Knlennic or e.\]jloring: 
needle, whioh is plunjzed beneatli the akin and the solution 
aliowtnl to flow into the cellular tissue by frrnvitation. 

After reaction bus l»een establisheil, the woman will nutfer, 
]H'rha|is for several days, with neuraltfia, headache, and ph*v 
tophul»ia, due to cerebral an:emia ; hence iron. <)uiidiie. and 
nutritious iliet will lie re<pnred, and opium to relieve the [tain. 

Sicondary Post-jtariaf Hemorrhage ( Puerperal^ or linnote 
Ilt'inorrhttfff) niwy occur within three or four days, or even as 
many weeks, aih-r Inlwr. U» cfiuAen nrf.: retaineil hlood-ehH8, 
membrane**, or piet:es of placenta, or (perhaps unsuspected) n 
plnixuitA 9U(t«nturiala, in the uterus. It nuiy also arise from 
violent ment^il emotion, or physical exertion, or use of uleo- 
holic stirauhintii s<M)n ailer lalH>r. Fe<'al accunudatitm ; retr<v 
ilexioQ of the wondi ; laceration of the i-ervix : inversion; 
tbrondius of w^rvix or vulva; fibroid and |)olypoid tumors; 
and certjiin bU»od-i*hanpes, such as those of prof(tun<l arnemia, 
urainia. or miasnuitic |>oisonin^^ are athlitional causes. One 
wise occurrinj^ eijrht days atter labor, followed the inlialation 
of ebloroforui and actadte for iuttomuiu. 



454 



POST-PARTAL HEMORRHAGE. 



StftrtpiojjiA — Blecnlin^ niny poiiie on fiiiddonly (quantity 
variai>leX st4)|>. and recur :it interval. It may, or njHV not, 
be a<'roni[>nincHl !»y fftid ilisrharpwi, an<l septioaitiic symptoms. 

Trratmeiit th\wnth u|h>u cauw, which must Iw thoroughly 
invest ijrnU'd. In cytsc* of retaint'd cloLs or rfet'iintliiiesJ. remove 
them by tiiiger or blunt t'un;ttf, swnh uti-rine ruvity with tincture 
of iLHline, and tjive ergot witii tint-t. C^annalti^ Indica, ptt. iv, 
every fix hour*. W M'ptini'mic syin])tonis. crt'olin injfriionfl 
^^ uttriiie cavity, with can- to iufuri' their ininie<iiate return. 
Kt^trotU'ction will n-qnire rrplaciinent and a fnll-si/c<i Hml^e 
jK's'sary. The invcrtod wonilr nuK-^t, ifpoi^ilde, ht* ri'|daced, or 
a.strin^ent wasiiwi npplial lo the hleedinjr s*urfaee in case of 
failure. Whether or not the <'nuse have been discovered, the 
bleeding may he often arrested by vH^iial injections of hot 
water (115° to 120'^ F. ) continued for ten or fiUeen minutes. 
Should it fail, |Mick the cavity of the uterus with iodoform 
gauw. 

In any cai»e ahwdute ro»*t and mental (pdctude, wilh tonics 
— e«peeiully tiuct. ferri ehlori<li — «i;d mjtrilioii-j litpiid diet, 
as a matter of course. tMlier plnns of trentinent will be sug- 
gested by the renjoiuing eau^ie:^ hefore uieiitiout'd. 

MoRRii> Retention of the Placenta, from niuHcs other 
than inertia uteri, has been referred to as an a<lditional factor 
in the production of p(R*t-parti\l hemorrhage, it is commonly 
due to morbid a/lhfMion of tlie phicenla lo the uterine wall, in 
eonwMpienee of iiliiceiititis. or ini1iinimati<in of the uterr>- 
placeiitiii junction, havitiji taken place ilurinp prepiancy ; or 
there may have been ehroni(^ inrtfiniiiiHiion of the lining 
of the womb (endometritiy ), with hyperjda^ia of conne<*tive 
tiRSue, liefore impregnation. Abnornml placental ndhcsiuu is 
often nhi*ociate*l with, and is iiidee*i u cautK* of iirajvhr 
" hour-ijinAi<*' cotUracium of the Uterus fsee Fig. 241. page 455), 
which consiKti" in a spawnuMliccontnwtion of Home of the circular 
mu!*cular fibres of the womb near its midtlle, the placenta 
l)einfr retaineil ab*>ve the constriction, through which last the 
umbilical cord may lie lrace<l up from the oj* externum. 

Sjimnnoilir eoiitrnrtion of the oh in another condition by wliicb 
deliver)* of the placenta may be delayed. 

Trtatmcitt. — Spasm of the os, and (*|)asm of the circular 
fibres higher up. may both be overcome b}' demly^ roulimiottSf 



MORBID RETENTION OF THE PLACENTA, 455 

pressure willi tlu; liamL, the fiii^or-tmlK Ut'w^ n|ijinixiiimrL<I 
into a cone, or one Hn^rr |int in at n linic uuiil ;ili liitve 
entered], when the hand may l>e jrrndually fonvd ihrouifh the 
ronetrii'tion, comittT-prt's^sure hoinf; nlways nuule hy (lie other 
hand upon the ('uiKhis. The plaeentji is then, it' not adhtrent, 
simply L^rasiH<l l»y the haufl and <reiitly withdrawn diirinjf a 
ciMilrailiiHi of the nteniy. aid l)uiM^ art"(»rfU'<l l>y itn^^^ure on 
llie fundus and Ijy er^nU IT the orjran br adhennt. the 
nmrliid adhehiun must !)C hrokeci up. and the phieenla lorii- 
pletely separated liei'ore withdrawal is altein])ted. A Hn>?er 
— oue or two — must l>e iiwiuuated betweeu the uterus and 

Fio. 241. 





Hoar fiinn contraction oriitL-ruH. with cncyettncnt of the placcntJL 



pla<"enta at fi*)nie point already piirtially separated, or, if no 
partial wparali<iii exijtt, at a i>oint wl»ere the placental border 
i« tfiiek. anil then jtassed to and fro, transvernely through the 
utero-phurntjd jmielion. artinp like a wrt of hlunt "paper- 
kniffi," initil separation be eomplete. Another mode is to 
fintl, or make, a margin of separation as before, and then 
|MH'l up the phuenla with the liiijrer-ends, ndlinif the separated 
I>ortion toward the hand-palm u|H*n the surface of the Mill 
adherent pirt, as one niiirht lil^ up tlie edj^e of a hurkwheal 
cuke and roll it u(M)n itM>lf until it were ttirne<l <*oinpletely 
over and sejiarated from the plate on which it lay. Strung 



466 



POST-PAMTAL UKMORRHAOE. 



fibrous or HI)ro-<'ArtiIn^in(ni& — rarely, even |tiu'tially *wtiifi«ti 
— hands may rt'<iuire t<i Ite pin<-he*l in two lietMwu tin* tlitinWv 
nnil ami imlex-iiii^^T. (irnit wire w neawary to avoi<l 
jK-fliii;: up 111! ol)li<nio layer K}ii uterine miweular Hhri'. wliich 
nii^'lit split ili-('|K'r and dceiKT until leadinjr the linjrer-emls 
llirouph the uterine wall into the |)eritoucui eavity. Sliouhl 
such u Hplittinjr l^'^'in, leJive it alone and ret^nuneuee the 
i^imration at wmie other |M>iut on the |fliuM:'nt4il imirgiu. It 
in .'*<»nu*litnr.H otily iKtrwihU; to get the phwvnla away in piecvfl. 
TlR-we should he aherward put tO|ti:ether and exaniiued to indi- 
«ite what reniiuuitst are leil hehind. It may W quitL- iniprac- 
lirahle ttj ^et (Kit every hit, hut snnill reninanti^, t)r lliiii hiyers 
too firmly adliert'iil tor removal, do not dit^tend the womb 
enon^di Uv ereate hemorrliage from their l>ulk, and the snlv 
sfctiuent danger of »eptiaeniia from their <lecom|M.»sition may 
!>e ohviated hy injecting warm (2 jx-r eent) orot»lin water into 
the uterus, twice daily, until eventhin^r have t-ouie away. 

In easfcfl where the pla<-ent;i is retained from it« vnumafly 
larife >*izt\ hivik down one edfre of it with llu: fingera (o iruturc 
it* preiientinj: endwise inntend of Hat like a hulton hnttontni 
in a hiitton-hole, and then make downward anil httrhmiii 
traetion — aided by uhditmimii prn^nvf — to draw it through the 
(W uteri. To make the Utrhv<trd tra**tioii referred to, dig one 
or \\s\} fingrr-end« into the HuhtfUuRt* of the |>laLmtii, if it 
wuniot he grn8|x'd firmly enough by the fiugcr-<'nd.s, and 
manipulate as if uttemiUing to pnnh ii totcard the Mirntm. A 
part of the organ having thuH heeu made lo bulge tnit of the 
OH, relea.s4^ tlie finj:erft and liiM»k them into the placenta again, 
Itigher up. and hi on until it have entirely |hum.m1 into the 
vagina. 

When, in extnieting plaeentn artificially, the hand Iuih Ih^u 
inlrodu<fd into the wonih, the latter sliould he wjishetl out 
aiWrwnrd with 2 jK'r cent, freolin solution. 

InlrtHlueing the hnn<l inl4» the ratfitm for extraiiion of the 
plaeentu is »onietinK« sufficiently painful to vauee ohjection 
and resii»tanoe on the part of the woman, the vulvar orifii^ 
l»eing tender or |)erlta[ie more or less laeerate<l. A liltle firtn- 
IH*?** of puritom*. minu'time;* Ineking in the young praelitioiier, 
coupled with moral tneouragement of the woman, and gentle- 
of muuipulution, will remedy the difficulty. 




ISVEHSION OF* THK fTTERUS. 



457 



CHAPTER XXVI. 



IN'VKRSION OF THK UTERUS. 



The womb may he iiivertw! in vnrioii** degreep, irom a 
aimplc iiuU'titanoi) <if the fumliir^ to \t» ttein^ tiiriioii (•0111- 
pletely **\vrou^' suie outwiird," ami hanging iijiniiU' tlown in 
the vn^ua. It usually IjejriHS by " dcprritawti '* of llie fumlus, 
ihe top of ibe uterut^ heiug iutJeiiled like the holtoiii of uo 



Flo. 2£!. 




Tlirw* degrew of Inversion. 

n. Peprralon of fbndus. b. Uterliie ravltjr- r- Vagln*. */ 1** tt- N<irinnl line of 

ftindai before Inventon. 

ohl-fiiiihiono<l black Iiottlo ; this may ^o ou until the fundus 
rcaeb and t>egin to protrmie throujrh the os* into the vu^ina 
{*' partial invemon "), or the pr<)tru4linjr pnrt uuty come 
thrnuj^h more anil more, until the whole orpin he turned iu- 
Mf out {"com pfi if i7it^rftioti''). (8ee Fijr- 242.) 

Ofciuiionally inversion begins at the nwk, the fundufl being 
then inverted hiht fSee Fip. 248, pape 45m.) 

(hnst'n. — Under any eircunitttnneos inversion of the uterus 
h rare, but it is usually the result of misnianaj^enient — trac- 
lion on the rord, or u|M>n an unseparated adherent plarenta, 
4innnp the third 8tn^ of lalwr, eaj»eeially when the womb is 
not well contracted. Other cause*" are; a« artvaNy »hort 
umbilical cord, or one that is praetica/hj short from coiling 
round the child; smhleu delivery, particularly while stand- 



458 



lyvERsroy of the uterus. 



inp, ami when the uterus ia ovcr-distetnle*! awl relaxetl ; 
vi<4ent .•itniiiiln;; i^r tuii^niin;^ etlar!>i attt-r tU^Hvt'r)' ; fomhie 
anti iiiji]<li<'itius [»reA<iirf u|nni iIh* t'utnliiH (nun ahnvis whether 
in- th(? liaiid t»r hcjivv compress's. In rhnrt, n irliuai wcnnh 
may t"i' inveru*<l eithor hv prt^nuro trnm aU)ve or hy trucLion 
from l>eh»w : iuversioii of a wtOI couliaHrd uterus in well-nigh 
imp<«sihle. 

A very i'ew rami's have. oecMirreil nfU-r aU>rtiou antl in uu- 
inipre^nitotl uteri with |»)ly|tl wliose pe<liclfca were attached 
near the fundus, Init theM! huft lieluug tu gyneculugy. 

Fill. 243. 




TnviTilon beglnnin;; *t Iho cervix, (AfUr Dtncam.) 

StfniptojM, — Heraorrhape. faiutuew*. 'shock, pain, vt«iwd 
ami reelal tenesmus. AlHlominal palpnliou rfVeals **de- 
pre^-ion'' uf fumlus, and himunuul exaniinaliiMi. in '* partial " 
Hud "complete" inversion, demonjitrutes res^ijei'lively {uirtial 
or complete alinenee of uteriift from its nornuil jKwition in the 
pelvis. Diagnosis may l>e olisrured l»y a full hiailder (pro- 
duced hy the inversion), hut unih^ a catheter will relieve this 
difficulty. Vaginal examination 4lifl«»vei-s uterine tumor oc- 
cupying the vagina, together with the placenta^ if this last 
have not l>een preWoui*ly delivered. 

A fihrous pulypua (the only thing liable to l)e confounded 



TREATMEST. 



459 



with an invfrtwl woriil) ) nmy Iw <iiji<;iHwtiratt'il from tlie tiU-nw 
by its ciiinpffte initttt>fibiJitif^ il.s dttaf tnuti of rvutraviion when 
hitmlled^ uihI Ijv foiftunnij ittf ^itflicie ihromjh the on uteri ttp 
into the uniiirerftit nU'riue cavity, which Ita^i may, in any case 
of (U>ulit, !»* demouHtrate*! with the ntenne nountl. Feeling 
the wonih in it.s propiT jHwition, thrMU^h tho ahiloininn! wall, 
fh<»ws th(* or^iJiii is imt inverU'd, Uterine inversinn is hanlly 
like-ly to he Tnisliikrn for |Milypus, except wlien the orpin 
remains hivertvl for tiioiilhs (s^mieliiner' for yearn) allcr liihur, 
l)econiiiiijr reiliM'eil in size l)y iuvohdion ; such {'h:^*^ are calletl 
** chronic invei>ion," and pro|)erly hchai^ to ^ynecoloju^y. 

The pi'tffjnoiiin of viterhie inversion during hthor i:* always 
serious. The ^rcuL iniTneiliule ihiii^'er is profuse heniorrhii^^e, 
the morr profus<? when »8s<K'iale<l wilii inertia uteri, and |*r- 
ha|>s some s|iiisni of tlie os, Much depends \\\Hm the early 
reiluction of tlie inversion. Every niiiaite lulda to both 
daujter and ditticuhy. Exceptionally the plai^uta may he 
sufficieutly adherent to prevent ^rreat iieniorrhuge. 

^rr«/mrH^ — " iK'prew^ion *' of the finidus and " purlial" 
inversion may l>e readily redu(v<b hy passing the hand into 
the wonih and pushing out the indeuttni |>ortion, wliile tiio 
orjrau rs then stimulated to contract 

When inver>jiou is •* complete.'* re<iuctiou nmy still \>e easy 
if attempted at once, luit not so after delay. If the placenta 
l>e still wholly or in great pnri adherent, it shonhj he ni- 
tempted to push it hack with the uterus, the chiM-d list being 
presse{| against the ilepeudent fnudus, on whi<li the phHenta 
forms a cUBhion. while cotirttrr-jtrvji^urr m vnnfr with thf other 
htimt uvtT the abthmen. When the hulk of the |»hicenta inter- 
feres with re<luction. and when it Ls already in great part 
detiu-hed from the wond», its He|>anition nmy l)o completed 
l)«fore pushing Itaek the funduA. When eonstriction of the 
OB, and other causes, have producer! swelling and e«>ngefltiou 
of the inverted uterine body, the latter must he tfmiprcwed 
between the two hands steadily litr a few nuiments In lessen 
its bulk before reiluction is attempted; or this nmy Iw ilone 
more etiectually by Inuidaging the iuverie<J orgau with a Htrip 
of iinloform gauxe. 

Shnidd spasnuHlie (wnstricthm of the ns render reduction 
im|Ki«*il)le even by sfendif^ firm prej<»ure, ana^tliesia nu»y l»e 
reiiort«tl to to relax the 8|uiBm, but the main principle of suo 




460 JiurrvJiE of thk vtehvs, vaoisa, eiv. 

oosiR ill i\\vpj^ fiuH« is to inaiiitaiii toniinned jtrf.HMun; without 
any iiitermiwioii, for five, ten, or iitWcn inin uU*, and wilh 
likti CDhtilitU'd tumiiitT-firr>iHnrr. 

Ai\.*iT retldctioii, \\\v Imitd itiiii^t not W* wilhilrawn from the 
uterine iiivily unlil the oriinn liuvf Iteeii niiulf tu ronlraet, 
ami the pJaivntn, it' |al^lht*ll hack witU the unnih, muHt then i>e 
»t-]iiinit<'<l and sv'uhdniwn, as in other tast-s. 

To I'urtht'r prevent a return of the inversion, the uterine 
cavity shouhl he irripttte*] with hot water — \\i)°-V2S}° F. — a 
quart or more may he re<juire(l ; it seeurc* Hintnu'titm and 
arrwiH hleediii^'. 

When the dejiendenl invertCMl fundus refuftefl to yield readily 
to manual presr^ure, one or holh of the anjjh's of the womh, 
where the Fallopian tulws enter, may he first iiuleuted iu the 
o|*eralion of reduetion. Inertia and hem(»rrha^e resultiug 
frtuu, or eomplieating inversion, re*juire the remedies for pust- 
[lartal hemorrhage. (See Chapter XXV.) 

The HtrideHt untiheptif ttidiuiciue muHt, of tx>ur»e, be ol>- 
servetl in all tluse nuuiipuhtliuiiH. and, after the inverted 
wonih is Hnally replared, iU* eavity uiunt l)e wiL*hed out with 
the creuiin solutiou. 



CHAPTEK XXVII. 

BUPTCRE OF THE UTEBITB, VAOIKA, ETa 

Rupture of the Uterus may occur in any dtfwtoi, 
transverflely, hmpitndinally, or hoth; in any jtoaitiojh fundus, 
iHwiy, or niH'k, mni't fre<pu'ntly toward the la^t : and in various 
(Jerfrern — that is. throu>rh (he nitis^'idar wall without rupture 
of the |x*riloneum — *^ iiirompUte rupture" — «)r through both 
{»eritonejil and rnuwidar eoat.H — **coinpftte rupture.** 

(^iHM'fi. — Stromj ufrrittr confraciion rtnipfrd wUii inechanicai 
impnlimfnt to jtfuwifjr of chiU — conditions existing in trans* 
veree presenlalionis [H.dvif deformity, or contnietion, and with 
lur^jfe size of tietus, ei*[)eeiaUy of the fa'tal head. a.s in hydro- 
cephulua. ul)t«tru<'tion from tihnad or other tumors, uic.; ihtti 




nVPTURK OF THE VTKRVS, 



461 



danj^or in all of llit*e case* is iuoreaset! Iiy ergoU which is 
Hometinies iinfortuiiatfly givfn. < h-niHiortally nii>t«re occurs 
withofil olK*t.riicttoii to piiAsa^e of child : it in then explained 
hy (i:tHiie dfijenerafiou — fatty, fibrous, or tubercular — of the 
uterine wall ; or the t<'ar may oi'cur nt the site of a |»reviou8 
rupture, or through the old scar of a former Ca^sareau section, 

Fio. 3M. 




contraction 
ring 



monl 



-- internal ca 



— rxternal m 



Arm prcseuUiUon with thrcalrncti rupture oftMnned lower segment of 
utvrus. (Aft«r!lh'MKOi>cK.) 



It may also result from traumatic injury followiDg blows, 
falls, squeezing:, etc. The uterine wall is, rarely, nipped and 
pinched Iwlweeu the presenting? j-jart of the child and fthiutr- 
mal sharp wljrcs of Wnie projectinp into the |H*lvic canal, by 
wliirh a wdiition of cuntiniiitv — the lH'j.nnnin^ oi' rupture — ii* 
pmduceil. Midti|>arity, and the thinnio^ of the uterine walls 



462 HVPTVHK OF TUE UTERVS, VAGINA, EXt\ 

due to frequent chiMhoariiig, are |»rpdip|Kisin£? rniiaeH. Ante- 
Hfxioii, autevfr?ion. rervic-nl nlthtriKtion, lUKi latiTiil obliquity 
of the utoni.-*. nir»>;titute other irisinnct's of mecliani(^-al hin- 
(iuruiKvtoluIjor Ijjihle to l>tMUtt.'ii<leil with ru|)turt'. Tliu womb 
may be ruptured by violent iiml unskilful mauipulatiooa 

¥w. 245. 




Thlnnlnc of lower Moment of titcrus In oli^trucifon (hnn hydroccpbaliu. 
(After BAnuL.) 

durinjr Ycrsiou and fftrirofwi o|K'rntioiii<. Inflammatory chan^fCR 
in llie uterine liasut-s, due to prolou>rt^d |>re8aure between the 
fd-liis and j)e]vit' wjiUb, eitmlufe lu rupture— even uJi'eratioa 
and pnnjrrene niny m-eur. 

Nf/m)W*fj/M.— AltlhMi^di rupture jrenerally fHTurn suddenly and 
williout warning, the exiisteuee of conditions mentioned uiMier 




RUPTURE OF THE UTERUS. 463 

the head of "causes" ought to be sufficient to indicate tlauger 
of iho lUM^ideiit. In the more usual canen of mechanical olv 
wtrurtit>u there *i*-<-uis, ?ome time before ru[jture, n rcninrk- 
jilih' tliinniu^ and HtrelcKiriir of the lower w'gnieJit of the 
\itenis, \\\nV' the ti|i]ier and middle segments of the wondi 
lire thirkeiu*d, llie line of <iivission helween ihe (hin nnd thick 
j»ortions coni?titutin^' a |x'ree|>lihle ridjre or fnrrovv\ i-onunouiy 
knowu afl the *' Ring of BotuUy'^ or more familinrly of late as 
the "relractiori riu^." Tliis condition in shown ,iu Fig. 2-t4 
(page 461), illiiplriuiiig the result of (indon^ied lalK>r in an 
arm |>resentatiun. On une side fidly hnlf of the nlernt*, 
extendinj: from the shouhier of the chiM |i> the top of it* head, 
ir* tliinni'fl a.-* deserilM*d. The wime nmdilion npjK'aTs in Fig. 
Ii4'i (page -lii^), 8howin^ olistruetion from a lar^^' hydro- 
ee|ihidir head ; the thin, Hlretched jmrt of the uterns extend- 
ing from the os uteri, uu a level with the [Kdvic l)rim, up to 
the child's ami. 

It \» rluH thin jKtrtion that is psperially liable to rupture. 
The increased thickness of the up|HT se;iment is explained by 
mnseitlar retraction, and by what hai* been termed '^ mujratictu " 
of the niiiscuhir layere — they separate from each other; some 
sli[i up by eoutraetiuu, and leave ihe wall below thinner, but 
thiiken the i^irt above. (See Fips. *J44 and 24.5, pMgi.»s 4til and 
462.) Prnaiintj ruptnre, therefore, the rinjr of Bandl, ruimii)^' 
obli(|UeIv or tratiHverrtely across the uterus, may be dLscnvered 
by abdondtml [ml[>ation. and as the jmuus — usually nipid ami 
violent — progres*s. the rine: pets higher up toward the fundus;^ 
the t'onnfi fitjammh may also be fell as tense rorrlx through 
the iilnJonnnal wall. The vntjinaf wall may a!s«) l)e tense 
ami j^tretched. Such conditions indicate (lnufjrr nf imprh(Uv(j 
riijiiure. They are often coupled with syTnjjtonis of genend 
exhaustion from prolonged ertbrt, viz.: sniaH, *piiek pulse; 
hurried breathing ; anxious expression ; pronounced meutat 
dejspotideuey or despair, etc. 

When rupture actually occnr>i the typicid symptoms are: a 
sudden shtirp |H»in in the wondi (caused by its tearing), some- 
times accompanied by an audible noise : sudden nnd simulta- 
neous cessation of lal>or ^»ains ; a sensation as if warm fluid 

t IU<ruri- liitHir UfKliiR, tlio rvtnu'tioit rliiK in eitualvd ubuut :t litelu's »)kivl> tho 
tutnlmmm; in impt'iiitlitt; ru|itiiri; It inny be felt through the aUluiuiiiiil wftll 
'i fnt'heD iibovv tJte ptdteM. 



464 RUPTURE OF THE UTERUS, VAOINA, ETC 



Creally blood) were being diffused into the sbdoraen ; violent 
Bhock and collafHf. in<iiaitod by pallor, tbeble and frequent 
pube, cold extroiiiitit'S, fUinlinjr. Imrried respiration, vomiling, 
etc. (uflimliy due to lu-niturlui^t' into ihi' [H.Tiloneai aivity). 
On Viifjimd e^iinhfttioit (lie pn-^nting jmrt of the child ia 
fftnnd to hove retvded Jroni \Ia former Hitunlion, owinj^ to 
partial or eoin[ile(e etrCajH] of the fwlUH thiuuirh the rent into 
the aUJonnmil cavity, wliere, by nbhnnuuf jafputiim it may 
lie felt as an irn^i^ular-shaped, movable tumor, more or Iraw 
distinct from anotlier tumor formed by the partially con- 
tracted uteruf*. Blood may or may not escape from the 
vajriim. A loop of intestine may prolapse through the rent 
and \)e found by vajjinal examination. 

The fore^oin^ array of Hyniptomi* would leave no room for 
doubt in diajgurwis. But when rupture takes place more 
gnidually.or Ih *' inrompUie*^ — i. e.. when the mutKudarcoal otiftf 
i« ruptured, the |>erit<)neum remaininjy intact, the symptoms are 
less decitle^l. The child will not have e«ctt|)e<l — at leaijt com- 
pletely — into the abdomen, but will he contained in a tftretehe<i 
pouch of peritoneum, so ten»c that the different parts of the 
child cannot lie recognized in it by abdominal pal)>atiou. 
whereas in " compfetr ** rupture the fn?tiil |>arts are rasi/tf 
reooj^ized and can be easily moved alK>ul» renting looeely, us 
they do, immediately l)eneath the abdominal wall. The pre- 
senting |mrt may or may not have re<'ede4l. In a ^a^lually 
progrewive rupture lalior pains may ooniinue and force tlie 
child gradually throujrh the enlarging: rent. In .some t*ai*es 
the presenting \t&Tl lievoiuvA impacted in the {lelviH, so that it 
cannot recede. 

PrognoKiA. — It must be understood that rupture (laceration) 
of the catfinai poiiion of the cervix uteri may, and frequently 
does, occur during labor without any neccfwary imme<liate 
danger to life ; but in the«e the tearing doies not involve the 
peritoneum, and e^^icape of blood, etc., into tlie al>doininnl 
cavity. 

Rupture involving any portion of the womb o/wiv the 
vaginal |>art of the cervix is a different affair. The prognosis 
is here moi«t grave. Death may en^ne rapidly, eitlker from 
profound shiM'k or henn»rrhage into the |«'ritoneum, or, sur- 
viving th«^ dangers fatal peritonitis and wptica-mia may 
Rhortly follow. The maternal niortaliiy much depends upon 



RUPTURE OF THE UTERUS. 



465 



the severity of the ra«', the extent of rupture, and the treats 
nieiit adopted. Fonuerly it was t;tated only one out of six 
cases survive*!, hut by the timely j>ert(jriiiinuv uf laparotomy 
the rf«ult.s hfive heeonie m inin'h more t'uvoralile that over 
half (he women are naveil. The ftvtal mortality in blill 
greater, survival of the child hein^r n nire exeeptiou. 

TrentmciiL — Before the tx-eurreuee of ruptuiv, but when 
exi^itiug eouditious indicate au evident liability tu the aeci- 
(h;nt, every means of prfvcniion nuiet lie atloptetl. Th(»ijgh 
gowl may lx» done in certain c-ast^s by the reetiHcalion of mal- 
preficiitationfi, uterine oldiquitien and flexions, f^till the main 
|»rophylaetic res4>rt Ls (/r/('cfTi/, either by force|»e, version, 
craniotomy, or whatever other methtxl the cinniinHtanrei* of 
the case require or will iidmit. Whatever method iri iiilipj)ti.H], 
extra care is necesnary to avoid violence of maiiijinlalion, 
piirticularly when version is attempted. The thin rli^iended 
lower se>:ment of the womb may be easily ru]itured eveii by 
mmJerately violent manipulations, and in ta-ses where the 
child \a dwid» craniotomy and embryotomy shouhl l»e resorted 
to by preference, notwithstanding suthcient amplitude of the 
[xdvis to arlmit of version heing jK^rtbrmed. 

After rupture has ocvurre*!. ey()ecially if it tie at all exten- 
sive, whatever in to be done had best lie d<tne fjuickly. There 
nnitit be no delay. The results of modern practice and the 
weight c>f prfifeftiional opinions have of late strongly tended 
to the miiclii»ion that laparotomy (cutting through the abd(»m- 
ina! wall and taking out the child, blood-clots, etc., through 
the incision) Hhouhi l>e at once performe^l m all ciue» of exteu- 
«iv uterine rnpiure. 8uch a rule, howevef, ha£ not yet been 
finally adopteil. 

When tlic alidoinen is oj)cneil and the child, etc,, removed, 
the rupture in the uterine wall is 8uture<] iis in Cesarean sec- 
tion ; Itut should the laceration Ik; of 8ueh a chamcter or in 
8n4'h a dire<'tion as not to admit of I>eing securely sutured, or 
shouhl the uterine ti.ssueii be much infiltrated, bruised, or in- 
flamed, it may be best to amputJite the womb by I'orro's 
ojw'rntion. (!^»e Chapter XX.) 

The chihl slioiiUl certniuly be delivered without delay iu 

all caseji. Tina rule is invariable. The moiU of its removal 

is the difhcult ()oint to Ih? detnded in a special case. In this 

decision but little value must be accorded to the life of th« 

30 



46r) RUPTURE OF THE UTERUS, VAGIXA, ETC. 



child. It will ^enenilly <He. 8houM craniotomy or ccphalo- 
triiiny. tlicrefurt-, upjw'ur U> ulFord tLe KiKHslit-pl method of 
delivery, they may he eniployeil. even though the child still 
live, and though it were |>fn«ihle, with a little more delay, to 
extract it hy veri-inn or ("orceps. Delivery, however, through 
the nnliirnl (m.HHnt;es mtiM nut he atfnuj'tnl hy iiny operation, 
when the child ha» entirely, or in a ^^reat measure, cwaped 
thronjfh ihe rupture iiiio ihe cavity of the alxlomen. Then 
laparotomy it', wiihuul «|iu'stion, the prcferahlt* resort, 

)Vhcn, on the olher hurid. ibc child has not t^scajKid ; when 
the OS uteri Ls dilated and the head presents; and when there 
is no mechanical olislacle to rapid delivery hy force|)6, this 
inatrument may Ik* applied. If necessary, and the pro|>er 
intitrumenti) are ohtaiuahle witluiut delay, perforation of the 
skull may jirecede forcejjs. In other cases, when the child 
Ftill remains in the womh, hut delivery by forceps is not likely 
to l>c rapidly surcessful, the main resort ip version by the 
feet- Kven when part of the child htiM c«'Mped into tl»e ah- 
duuien, providetl it lie not loo jzreat a pari, version may still 
l>e i>erfornie<i. The utmost cure is necessary to avoid enlarg- 
ing the rupture and pulling down a loo]> of intestine, aud 
when- the child is delivere<l. extreme caution is required in 
delivering the platvnla. The ruptured womb will not expel 
this last spttnlancously. The Imnd must he piissed into (he 
uterus for its withdrawal, ns in other cases. If the placenta 
have esc^i|)ed through the rent (which is unusual wiiejj the 
cfiiM has not done sot, trartion may he made on the cord to 
bring it near, or into the tear, so that the hand in the titerua 
may get hold of it without the ne<'essity of pas.>^iug the hand 
through the rent into the abdominal cavity. When delivery 
\s complete the cavity of the womb must be washed out with 
creolin s*>lution (2 |)ercent. ) and tam]Hmed with iodoform 
gauxe — the latter serves Itoth for arresting hemorrhage aud 
for drainage ; the gauze may remain two days. 

Subucqnrut Trvatmntt, — i^limulants to counteract shock and 
c^dlajise from hemorrhage, Opiat<« to relieve pain. Daily 
cleansing *tf uterine cavity Iiy the creolin solution. \Vhen 
the child has been delivered by the vagina, some re<'ommeud 
that the imizzIc of a syringe l>e passed up into the uterine 
cavity and through the rent into Ihe jieritnitrtii cavity, which 
last is thoroughly washe<l out with pure hot water (100° to 




i 



RUPTURE OF THE CERVIX VTERl 467 

104° F.)« aud a draiu of iodofonu gauze afterward placed in 
the uterus. 

From the dreadful mortality following rupture of the 
uterus the ijn[»ortaiioe of prevcniion in the ditfi^rtnt ca8«* 
when it is likely to occur eaiiuot be too ardently arcentuated. 
Thus, in inii)endinp rupture with cross presentatioD, dts^tipi- 
tatc ; with hyilroct'pluiliih, jK'rforate ; iu hrewli pri^i'uUUiona 
deliver with Uluiil hank ; in cases of pelvic narrowing the 
rwjuired o[n^rative lui'Hiods must 1h; done witlwnt dtfay. As 
a gaiernl raiet when the tower se^iueut of the womh ia gn-atiy 
thinned, version ia couira-iuilicate«L 

RurrrRF- (LACERATinN) of the Vaginal Portion op 
THE C'ervix Uteri. — Hlijcht superticial lacerations are very 
common, and often unreco^ni/Axl. Even ccnwiderahle one8 
ptL^ urrnolicfHl hy llu^ olwtt;triiian more fre4|ucntly than they 
would if properly sought for, n» they should l»e atler lalH)r is 
over. 0(C:i^ionftlly thoy extend up V) the utero-vaginal junc- 
tion, or into the vaginal wall. SomelimuH tranitverse iu direc- 
tion (thuugh generally longitudinal); pieces of the os may 
hong downward in the vagina, and rarely an entire ring of 
the vaginal i^ervix may be gei>arated. 

CatiifeA. — DiBtenlion by the presenting port of the cliild 
during lalM»r; rough manipulatittiis during version. force|«, 
and other operations ; incarcvratiun of the anterior lip of the 
o« l)elvveeii the hea<i and [telvis. Titwue-changesf prt^venLiug 
dilatJition of the i»t, and priuii]«vrity, e#|XH.:iully ii» elderly 
womciu are priHiis|H)sing eausen. 

Sijmptoum, — Hemorrhage, more or leas profuse, according 
to the extent of lar-eration, the latter to 1h* diagnosticated by 
digital examination, or, if necessary, by ocular iii8|)ectJoa 
with the speculum. 

yr«ro/;«CTit^^light laceratioufi get well rapidly without 
treatmeut In more severe one* hemorrhage may i>e ^vntrollwl 
by application of the solution of f>ertiulphate or perrhloriile 
of iron on crtjtton plugs, or hy a tnjn[HKi of itxhiforni gauze. 
Extensive cerviral lacenirions slundd he unite<l at tmce by 
hutures of catguts ttilk, or Hilkwonn-gut ; (his preventj* the 
sulwe<juent occurrence of congestion, iitHainmation, and hyper- 
trophy, etc., of the cervix, which may rwjuire restoration of 
the lar*eration by sutures, etc,, montlis or years ailerward. 



468 nUPTURE OF THE UTERUS, VAGINA, ETC. 

The auturiii|i may Iw flune with llie aid of a Siiiiin's speculum ; 
or the \v(mil> iiiiiy lie jmslieJ tluwii hy ulnluruinal pre^wure 
troiu iiimve until the cervix hecome vinihle at tlie vulviu 

C'jirlM)liar'il iiijinlimis into ilic vn^'itm for a ft*\v days after 
hiiwtr, wiu'ii lacc'raiiini cxist.s, sliouM always lie employed to 
prevent aliyorplion of septic inatlL-r hy llie raw suri'acw*. 

Lacier ATio.Ns ok the Vagina itself, *>r of the Vagikal 
Orikice, are reeojrnize'l by dijfitul examination or inspection. 
Rarely, Pti|K»rficial or inorlerately deep la('erati<»ns wcur near 
the untrrwr f-onimis'^ure, involviiijf the nym}>h:e, vwtibule, 
urethra ami ilj^ nieiituH, Momelimts Mith consifieriihlo Meeting. 
They rcfjuire autiHcplic cleanlinw* — (lu^^liu;: uilli iudoform — 
ami, it' »leep enou;j;h to caune hemorrhajre, suturet* of tine silk, 
which uiay Ih.^ reuiovdt iu four or iive days. 

Rrm-RK OF Tuv. Tissi:i>< dp the Vulva — of their inner 
tissues and blood vi-sM-lh — without any nettssary laceration of 
skin or muciMiH membraue — may occur either during or after 
hilvor. IJI(hm| is iiiime<iiutely extravuwited, (siu^iu^ the labium 
to swell rapidly, and constituting a hiemntoma or thrombus, 
to Iks now d('>krrihefl. 

Thrombfr of the Vulva. — A tumor — bluish in color, 
elastic or fluctnaling, awon\panie<] by sharj) \w'n\. usually on 
one side — forms rapidly, sonictimei* of nuHicient size to pre- 
vent delivery m(H*hanically. It may hurst and lead to profuse 
or eveu fatal external hemorrlmjre. Extravasation may ex- 
tend upward oulnide the va;»innl wall to the uterufl, or even to 
the celliihir tissue of the iliac foHca. ur behind the |^ritoneum 
t4t the kidneys. 

The protjmmH in variable, according to the extent of the 
uijury aud oxtravusiititm. Death may reitult from hemor- 
rhage, or fnmi decomjMwition of retained cbtts and He[)tica'mia. 
In many CBi*eg, of nio^lerate extent, al)#»orption of the effused 
blood and re<^>ver)' take place. 

Trmlmnti, — During; lalMir. delivery, should he hastened — 
preferably by force|M, and lliis rwr/r/ — before the thrombus 
has had lime tn irrow very larjje. If ilH size prevent delivery 
the tumor munt l>e iuci«ed» the clola turneil out, «ul>sequent 
hemorrhage oontrolled by comprestiuoD, or pledgets of cotton 




nVPTURK OF THE PKRIKF.VM. 



469 



containing solutiou of perchluride of iron, ami delivery by 
forceps* rnpidly t'ompU'ted. After lahor, when the thromhiis 
ha.« ln*i*ii opened, artilii'iwlly or ollierwij+e, styptii-si and coni- 
pre«*ion may Hiill Iw retpurt'd t(» prevent fnriher lileHliiig. If 
delivery have lieeii fonj[»lele<l without opening tlie tuinur, it 
must he letl aloue tor absorption tu take phiee. Should sup- 
puration oeeur, as somelinit'H hap]>eiis in a few day^;, the part 
inuwt lie incised lo give exit to pu;* and clots, and antiseptic 
treutoietit of the wound adopted to prevent septie infection. 
lu all eaneH ahwdute rest in the reeuniheut iNjslure and the 
avoidanie of ^trairviiig efforts of every kind are indinjiensaMe, 
lo prevent reeurrent-e of hemorrhage. The Meediiig (ur ex- 
travasation) may also he controlled Ivy vaginal hydrustatic 
pretsure, an elastic ruhher hag, or Barnei»'s dilator, tilled with 
ice-water, being iiilnHiiiced into the vaginal canal, for a few 
hours sul^wHpicnt to delivery. (_'arl)olize<i wanhes to he used 
atler ita removal. 



RuiTURK OK THE Perinelim. — Cuuscs uud uiode of pre- 
vention of this accident during labor have already been con- 
sidered. (See <.'hapter XII.) 

Every woman ought to be carefully examined after de- 
livery, by insjiection of the [inrts, tt» awertain if |)erineal 
laceralion exi(»t. 

Slight liftsiires of the posterior commissure, or of the four- 
chelte in priiniimric. usually heal ot' themselves withi)ut treat- 
ment. Extra antiseptic cleanliness i.s however, advi»able. 
Even tears of apparently consideral>le Mzt^ shriuk almost to 
nothing when the tiw*ue8 have recovered from the distention of 
|uirturi(ion, a." they do in a short time. The extent of rupture 
may Ini either seen ur made out by pasj^ing a finger into the 
rectum an<( tluitub into the vagina. s(t as U) hold the remain- 
ing recto-vaginal rt»ptuni l>etween the two. Exiecaivu lacera- 
tions often involve the sphincter ani, posterior vaginal wall, 
and rectum. For convenience of de.«criptu»n, hicerrtti4)ns of 
the j>enneum have been divided, according to their extent, as 
follows i those extending from the poMorior comndmure half 
way to the anus, are ciillwl lacerations of tlie fimt dt-ffree; 
those extending to the anus but tiot involving its sphincteFt 
the Afcond degrer ; and thtwe exleudiug through the sphincter 
ani into the rectum are lacerations of the third degree or 



470 RUPTURE OF THE UTERUS, VAOINA, ETC 



compkte'' ruptures. Rarely 



» 



I 



I 



out auv teanuj? u 



r tht 



tukes 



place, 



lH*tween tl 



centml" perforatiou (with- 
poi*tenor ('uinnii«iire of the vulva) 
iti two (»i)eiiiiij^ ol* the vagina aud 



rectum, through which the chilil may pii.s8. 

While the ditttfttnsis of huvnitio!i ami its degree is mmle 
by iu.**peetiou and ilijtital nmuipultUiuii, the ittjmptoms of ptiin 
and JtoreneAJi at the sent of injury, iinil luore or less blee^liug 
from the wuuml. will, of course, l>e present 

Treatment — L'ulei« the lawration be cjuite insignificant, 
the treatment consists in bringing the freshly bu-enited sur- 
faces together by silk or catgut sutures immcdiatehj ajftr htbor^ 
This is to l>e done, whether the ssphinoter ani be torn or not 
In fact, the more exteii!?ive the laoenition the more the neces- 
sity an<l greater advisability of stilchiug up the rent. In 
bad cMiH.'s, fi^^piiring extni surgical skill — uot imme*Jiately 
available — a delay within tweuty-four hours may Im* justifia- 
ble to ol)tJun it, anil woulil not make very material ditlerence, 
a|>art from disturbing the woman when she ought to 1)6 al refit 
III lacerations of the first and second degrees [not involving 
the pphincter ani and rectum) the 0}>eratiun is not difficult 
The woman is laid acroHs the be<l, her hi|is brought to the 
edge of it hor lower HniKs held by iissi.stantii and flexed in 
the lithotomy [jositioii. Ameslbesia by etlier, or lo<^'al amee- 
thesia by injecting a 4 jwr cent, sterilizwl solution of cocaine, 
nmy Ik? need, if lUM^essary. to keep the patient still. The ])arts 
are cleansejl and a pledget of sterile cotton or gauze pushed 
up the vagina to slop any flow fnmi the uterus ohwuring the 
wound. The sutures (preferably of aseptic silk) are [xissed 
with a moderately curvcil neeille about two inch<*8 long, as 
follows: beginning at the p(»sterior end of the laceration 
(that nearer the anus), the nei'dle enters the skin near the 
eilge of the wound and follows a circular course until its 
|K»int appears at the very bottom of the laceration (a finger 
of the other luuid in the rectum gnarding against its f)ene- 
trating that canal); it then enters the oppiosite side of the 
Jacerntion at the bottom of the wound and comes out of the 
skin op{>osite its ptant of entrance, luiving followed a similar 
circulnr C4^>urse to that piirsue<l on the other side where it first 
■ went in. Ttie ends are ^o»«Vytird or sccuriMl by calch-force|)», 
I tmlil the refjuisite nundier of sutures are pa»s«'d in a similar 
I manner (half an inch apart), when the wound is again cleansed, 



LOOSESING OF TBE PELVIC ARTTCVLATIOKK 471 

the v^aginal j>lug removed, and tlie Buturesi tied tightly enough 
to conpt the parts without iriji]ri<nifl conatriction. the order of 
fiuwesfijim in tyiii^' heiiigthat in wliicli lhe**»tures were |):utt*ed. 
In "coniplete" hicerations — tl»u»e of the third ilejtrree — 
throup;h the sphincter aiii to the re<'tiini. the ofieration m more 
difcult. The reetal tear \» first utitohed witli oiftjut sutures 
(a short, eurve*! needle heinj? used) and j^oiu^ tliroutrh the 
rectal wall only. The sulurw* are tied on the inside, si> that 
the knotji* nre on the niueoiis iuend)rane of the hmvel. They 
begin from alK)ve and come dowu to the tpliiucter anl, the cut 
ends of which are drawn out with a tenaculum while the 
sutures [>ene[rate them. These eatgul sutures need not he re- 
moved: they will digest in the tiasuen and di^aj)(K'ar of thein- 
selvea The p<>*;|erior wall of llie vagina I** next suture<l with 
fine silk, from al>ove downward toward the hymen. Finally, 
skin sutures through the i>eriiieuni itself, including muH^derf of 
the [Jt'lvie tloor (as just de«<Til>ed for lacerations of the tir»t 
and second degrees) c-omplete the o|>eratiou. The silk sutures 
may lie removed in ahimt a week. Antiseptic dreiwings are 
applied as after an ordinary lal>or, extra care Inking taken to 
keep the wound aseptically clean hy daily irrigation with the 
creolia solution. 

IX>OfiKN'IN<i OF THK PKKVir A RTtCULATIONP — of the puhic 

ayniphysis and sacro-iliac synchondrow^s — occasionally ttcour*, 
either from pathological changes in the jniuts, or from great 
violeuce during fon?e|is and other modes of artificial deliv«ry, 
or both conditions exist together. The ftyinptom.i arc, at the 
time, pain and iucrensefl mobility of the articuhitions, demon- 
stratetl hy gnmping the two iliuc bones near the anterior ex- 
tremities (tf their crest, one in each hand, and nMiving tlu^m 
slightly to and fro, transversely, in opix>gite directiuns. Atler 
getting up, pain may be absent, but the patient is unable to 
walk, except with difficulty. If two fingers \w piisH'd into 
the vagina and phice<l behind the pubic Hyniphyftis, and the 
thumb in front of it, while the patient, standing, reslp her 
weight fii'st on one leg and then on the other, or sways her 
b(Hly fnim side to side, movement of the pubic Ik>dc8 against 
ea<'h other may be recognized. 

Treaimrni. — Rest in bed upon the buck, and support uf the 
pelvic wallfl by a circular bandage uf strong umvatt or strip 



472 



MULTIPLE PREGNANCY. 



of rul»I>cr atlhesivo |>la^or about three iticho^ wide, paswing 
nuiml lliL' IkjiIv between the anterior Kujjerior Hpiudus pro- 
cesses ol* the ilia and trochanters; it nitiHt ^o juM UUnv the 
HpiiioUif protvj<seti so as mA to press ii|H>n them. It Hhoiihl lie 
worn for weeks or nmiitlis alU'r getting np. It may he made 
continumis with or attaehHl to a pair of t^liort hreiH'hes or 
light*! tilted »>n the upper part of the thighs, to prevent slip- 
ping up. Recovery usually results. 



CHAPTER XXVIII. 

MULTIPLE PRKllNANcy — HYDRO(EI*HAIA*8 AND OTHEB 
ENLARGEadKNTS OF THE CHILD. 



Thk Hinuillaiieoufct esigtence of two or more fa^tuscs in the 
womh in termed "innhi[tle" or "plural" pregnancy. The 
iiuniher of ova may he two, tliree, i()ur, or tiv€\ named, re- 
»|wetively, twins, triplets. *[uadru|ilet?i, a!id <jviintuj)iet8. Re- 
fMirled car?»H of more than tive are not well iinlhentimted. 
Twint* o<M'ur once in ahout Hevenly-tive cawf- ; triplets once in 
about tive thousand; qundrnpletB and quintuplets are ex- 
tremely rare. 

Plural pregnancies are produced by two or more ovules 
entering the uteruH and l>ecoming impregnate<I aliout the Nime 
lime. One ovule may come fnun each ovary, or twn from the 
same ovary. In the hater case both ovulew may come fnmi 
one Graatian fu!licle, or each from a gejiarate one. Again, 
one ovule may c<»ntjun two perma, like a ilonble-yolked egg 
from the fowl. These sievenil njodes of origin e.\p!ain the 
obfterved variation in the arrnngcments r>f the phuentic and 
fwtal mend)rane6 in ditferent caK*. <.ienerally each ovum 
(in twin cai«e«i) has it8 own sue of amnion and chrtrion, which 
comes in contact with that of the utiier n» gnmth advances; 
but the two sjK-H do not amalgamate; they remain separate 
till birth. In thew there arc two placenta*, usually sejMirate 
from each otlier. though they may he near together, or par- 
tially united. Iti other vixses f^ach ovum has it« own amiiiou, 



DTAOyOSIS. 



473 



but Iwth are conlAine^l in one chorion. In these the two 
phiceuUe are fused t*>,L^ether, or the two uiohilicul «*onlH may 
be uuitetl l>t'fore retu;hiii^ the placenta, lijirely liolh (tPtiifte« 
are eonlaiueil in tmv amnion, a^ well iw in 0[ie ehoritui. Here, 
apuid, the |iliuent:e are iiniteii in one uniss. Two ova con- 
Uiinoii in one ehoriou are oi' the same t^ex. 

Tilt! fact that the ves:^l.4s of the two ])lac©atie and of the 
two wrds nniy ina^Milate uith each otlier ( Imt wliiih cantujl 
be matle out liefore deliver} ), leails to an iiap«jrtant nioditir.'a- 
tlon of the luanagement of labor in twin cases, to be men- 
tioned j>re«ently. 

The irruwth of the embryos in twin Cfisefl ia seldom exactly 
efjual, and sivnietlnu^ tlie diflerencc is very preat, one child 
ajj|M.'arinp fully d«ve]tj|»e<i while the other remains very small. 
One fa'tus may die and l>e (brown oft" iin-matun ly, while the 
other renuiiiis till full term; or tlie little dead one may J^till 
remain in titem, and come away at full term with the live one. 
Thet*e variation!* are due lo conditions favoring the nutrition 
and circulation of one fivtusf at the expense of the other, such as 
fuklB or compression of the eord and coniprettiion of the pla- 
centa. When the two fietal circulatiou8 inoKulate iu the ct>rtl 
or plat-enta, one firtus haviiijLr a Ptrtmper heart than the other, 
favon* its hetter uutritiun and developincut. In tliis way 
acardiar monsters lire proihu-cd. 

Oct'iLHionally (uu- child remains for days or even weeks after 
thf birth uf the tirst ihk' l)efore it is delivercNl, and tiius cotu- 
])li'te.s it.s di'veiopimiit. Such ciLstw are Ik'j<1 explaine*l by the 
exii*ten<'e <d' a double uterus. 

I'himl births generally (K'cur a liule before full term, tlie 
decree of prematurity iucreaitinp with the iiutnlKT of fietuges. 
In twiiLs only a few weeks may Iw wanting of the usual 
period: (piiiitup!elrt are always abortions; the othern ai-e 
intfrmediate. 

IHu'jfio^U, — The certAin dia^noHis of twias before one child 
is l)Orn is sometimes dirticult, but the followinir data will often 
be sufHcient Ui render a diairniisis prolialde. and in wjme cases, 
when they are all available, a ])osilive diajjufwis may Ik* 
renche<l. On inHitrction, the alwiomen ap]>ettrs larjre in tnrje 
and irregular in Hha[>e ; the lower region of the ab<h>minal 
walls just above the pul>e8 is often swidlen from localized 
ttnlema. 



474 



MULTIPLE PREoyAycy, 



On jxifjifitioHj tlie skillwl haiui ilitRitivtire prrtdifteut tntslon 
of the uterim* wall — i c, in an ordinary (sinjfle) preguancy 
Uie womb Uc^'onies of a ifiiotlm hurihufui during ('(intnu*tii.»n8 
of tiic or^im, but mj'f awl j/liahfr between the wiiitrtK'tioiis, 
while in a wonih ovfr-<li(*l4'ntle<l with twins the orjjfan hecomc* 
hard tluriiij.'; contraction, hut <ioes not ^vt soft and pliable 
durinjf ri'hixation : an iuicrmtilutie tUtjrer of jn'rimnmit UuMton 
rfmnim* hetwfH'n the » "on tractions, which is neither wooden 
hnrdncHH nor pliai)lc *»ot^nci«. 

In twins there are ftiur fcBtal pfdes — viz., two heafl^ and 
two briHM'hw. Palimtion reveals one [K)le at or below the 
brim, another in an iliac fossa, and one (or two) wjmewhere 
toward the fniidnn ; or they may he situated ditterenlly. The 
resisting planes of two barks may l>e made onl ; and the niov- 
nble small (Mirtn (lindw) may lie felt a! such divert and wi*iely 
diBtanl iwrtrt of the ulerug as to make it inconceivable tliat 
they all Wonj? to one child. Further siifns : Exaj/jjoratiou 
of thowe conditions of prej^naiicy due lu jji-estjure of the jfravid 
uterus; the inj|>0!«il)ility of iMdotUmcnt ; the reco(jrnition of 
two f*tal hearl-«nnnlH, not svnchronons with eachotlier, hcjird 
loUfh«t at two different |K>intM of the alxlominal surface, and 
Iteoonnnp feeble or inaudible l)etw«^n these points. 

After one child in burn the existence of a ssectmd \r^ readily 
made out by the still lar;re size of the womb; by feelinp the 
child ihronj^h ib* widl over the abdomen ; and by a vapnal 
examination* recognizing the baj; of waters and }»resculing 
|»art of the setN^aid infant. 

Womeu who have burn iwina once are likely to do so npiin. 
The tendency to phiral birth8 is also herolitary in some casefl, 
and may be conveyed Ity the/*;//iPr; hence a previous history 
of plural birthy in iJie fannly may be of »omc value as a 
means of dinpniwu^. 

J*rof7ftot*iit. — Delivery of the first child URually te<liou8 from 
inadefpiate hd»or |»ains. due to overdist<.*nHon of the nlcrns, 
and from lon-e of uterine contraction beinjj uecetBarily diffmsed 
throuirb iMMbes of both children, instead of bein^ com-en- 
lrale<l u[ion the |)ret*i!nlinjf one. Delay iw greater when the 
first child pre4»ent.s by the breecli, es|>e<'ially so in delivery of 
the after-coiniug liead. PndoiijLration of lal>or, large area of 
placental surface, and overdisleution of the womK predisjKiee 
to inertia uteri and ]>08t-|)artjil hemorrhage^ Malpre«enta- 




TREATMENT OF LOCKED TWINS, 475 



ti»u«^ nro nmre fretiueiit tliiiti in Hiii>;]t^ 1)irtlii«. In altout half 
the <':tfleH lH>th rhildrcn prci^eiit l>y tlie hwul ; in luie-third of 
the v^gi^ one by head luul one l)y lirewh ; in one-ninth, both 
by the breerb ; and in one-tenth, either one or (rarely) both 
fhihlren prt^eiit tniiisverwdy. 

Excluding the (xmipliattions of nmlpreseutation, tlie oc- 
eurrenw^ of twiim, with i>ro]>er miiim^''enieut, need not preclude 
a favorable proirnwis in tlie great nmjurity of ciises. 

Trtntmeni. — Tie tlie placental end of tlie onrd whoD one 
fliihl itt Itoru, to prevent [MR^fiilile beniorrhaj;e t'roni the second 
child, owing to inamnihition of veftK'lrt btlMfen the two cords 
or j>l:u'ent;e, Ix^t the plact^nta alone niitil Jifler delivery of 
sei'ond chiUl, unlei«8 it be »|)ontaneoni*ly expelletl before then, 
when it may Ije carefully rentove<l. 

The alleged danger of mental bhoek from telling the woman 
she ie to have a eecfind child, in seldom i*erioijp, esi)ecinlly 
when she is told its delivery will be short and eaj*y. 

After one child \» Wyvu there usually suweeds an interval 
of rest from labor pains for fifteen ndnutes, Pometimes for 
half an hour or an hour, when conlraclions iiirain come on, 
and tlie second child is easily exjuHtHb the parts having lieen 
thorongblv dilntetl, and the seeoiid 4'hild Iwing usually smaller 
than the first. During the interval, when rest is advisable 
for recuperation of the i|KThaps exhansle4l) uterus, exandua- 
tion must be made to ascertain the preeeutation^ aud correct 
it if transverse. 

After an honr^ or before then if the uterus be "not exhausted 
by previous pndouged effi>rl, the membranes, if intact, may 
be ruptured, and the wond) niauipuluted through the alwlo- 
inen, to pnxluce contractious. 

In case of lieinorrhago, convulsions, feebleness of (he 
fietal heart, or any condition rendering imnitirmle delivery 
nK-essary, forcejis may be applie^l if tlie he»»i have tlcst^ended 
into the pelvis, and version if it have not. In either case, 
extract the child slowly, ao as not to leave an empty relaxed 
womb, every nieiiuH being takeu tosceureidmultauiHiua uterine 
contraction. 

When ImiiIi children are delivered, extra care is necespary 
to overcome inertia and prevent post-jmrtnl hemorrhage. 

Tntxtmeni of lAM-hol TtriuA. — When both children arc con- 
tained iu one amniotic sac, or when, there l^eJug two sacs, 



J 



476 



MULTIPLE PREGSANCnr, 



both huvG ruptured early iii latior, both children may preeent 
aod enter the jielvis together, and thus getting "locked" 
prevent delivery. 

When both headis present al the brim^ one may be pushed 
out of the way by combine<l internal and external manipula- 
tion, und for(:e|iti then uppHcd to the other to bring it down 
into the strait and cavity of the pelvis. 



Fic. 31ft 




J^icktHl Iwinn, (hiDi heitiU presenting. 

When Iwlh heads have jKis^ed the brim^ push buck the 
second one., and apply force|)e to the first (the lower) one. 
Should this be iinjiracticable from the heads having.' descended 
t(X) far, the lower l»eatl. and then the other, nmv l)e succes* 
wvely delivered by forcej*. Exceptionally, craniotomy is 
reipiired. The same mode of treatment may be ne<.*es8ary 
when one head, having entered the i>elvii; cavity, is arrt^etl 
by the jamming of the tliorax a^ainrt the sectmd he8i.L either 
at or afwve the |)elvic l»rim. (See Fi^. 246.) 

When [)ushing Imck the hacked presenting parts ap{>eara 



TREATMENT OF LOCKED TWINS, 



477 



inifK>ss-ible, it may still be uuule easy, in some cxi»qs, by placing 
tlie wanuiii in n kiuv-<!he.st |H»sition, which i*houUl ulways bo 
triwi iK't'ure uuy serious o|»eralion ; the parts go back by 
gravitation. When the first chibi prea-nts by the hrewh ainl 
its (lelivereii MS fur as the bwul. tlie latter may reniaiu aliove 
the briin. owing to ibe bead ot* ti»e secomi chibi liaving «lc- 
scendetl into the [R'lvic cavity, the bead of each child resting 
against tht' iierk uf the ulhtT, i^o as to lo<*k or Inji the chin? 
together, and prevunl further prugrt^s. {irm Hg. 247.^ 

FlO. 2^7. 




I-nrketl twinii— on« brvecl), one head. 



Diagnoeis of the exact arrangement of the complication 
having been n^ade by the hand in jhe vaginn, sieveml ditferent 
n)ethodj< of delivery are available, stdivtion of either lieing a 
matter of jndirrneiit rleterniiiied by the [«*cub'ariliej* of eiu'h 
caw. Af n rnlc. the life of the child \\ho(*e breech is delivcre<.l 
will be eidWddt'd or lost by conipre.«sioii of its funis, or it 
may be already rxtinct. Hence in wdection of operative 
measures i-uiH-rior value should be allotted tlie second child. 
The beail of the .«^^C1>nd child may possibly be pu.«<hed uj> out 
v)f the wny for the other tr> pass. The seconrl head mtiif(t) 
be flelivertnl by force|tfi, while the first remains, but not with- 
out difficulty and great danger to l>oth chihlrcn. The head 



478 




MULTIPLE PREGKASCY. 



of the first child may he punctureil, or even dccapitnted, eo 
fts to allow extriiflioii liv forceps of ilie soroml one, the Iwdy 
of the first (wheu decMi|tiiatiuii luis heeu peiloniietl ) heiug, of 
course, previously rtiiiiovwl ; its hea<l coniiuj; attt-r the other 
child \» born. This liu>t uielhtHl pnihuhly iiHbrde the best 
chance for the second child. Most frc<|Uently lK>th are U'>6t. 
When t!ie lives u{' lK)th are extinct iM^fort* lUlivi-n* tiiere still 
remain!* another rcM.ut, viz,; tluit ol' piuiclurin;: the second 
head nml delivering; it hy forcofis or cephalolrihc past ilie 
body of liu^ hmer child. 

Tlie o|>eratiini of syin|>hyiieotomy would peem to he a feagi- 
blc metluKl of relief in locked twins, but ciiHis have not yet 
been rejujrtcd. 

\n cufies of coujoiurd tiviu9 — double vionfiterA — when the 
nattiral powers are insnfticieiit for deliver)', version by the 
feet, and jnt^ibly aoWquerit mutilation, afford the best means 
of relie£ Mutit tfucL ciuies are, however, deliveretl tpoulaue- 
ously. 

nvi>ROCEPHA!.rR — distention of tlie skull from accumula- 
tion of effiiHcd Si rtiin — <N>nst)tutes n dntigerons iiii|>edimeut to 
delivery, leailin;^ to rupture of the ulerus. or dangerous in- 
flammation and Blougbin^ of the mother's soft |mrls from 
their pndongnd (M*mi>re.'^sion during a tedious lalmr. When 
sliglit in degree, lalwr iiiay. however, lermituite )*|H.Mitaneougly 
without danger. In extreme vnn^ the child's head is as large 
as that of an adult. (See Fig. 248, |>ege 47!^, also Fig. 245, 
page 462.) 

[yuiijuofift, — r)illicult early \\\ liihor. Strong pains con- 
joine«l with a (known) normal pelvic, but without exj^iected 
descent of the bead, t^bould excite FU^(picion and induce a 
careful examination. Owing to unusually large size of fa-tal 
heiid, the childV body is higher np, hence Boumls of fu?lal heart 
heard level with or even alxtve ihe umbilimg. When head is 
arrested alxive 8U]K»rior strait. pa>ti the \vh(de hand into vagina 
(under ether, if necesMiry from pain) aufl I'eel tlie bead. ItB 
large size, wide, and ijorhaps tlurtiiatiog funlauelleH and 
suturt'si are tturticieritly clidractt^rislic. The head is left* convex 
and ftflM more like a tiat lid over x\\v. |>elvi<- brim than a 
globular ma»i. The hulure** and foutanelles become t«nae 
during a \m\u. The cranial boncii ore tei« ressiiitant to the 



HYDROCEPHALUS. 



479 



finger. An enlarged pn»terwr fontanel le is very (ngnificant 
The proniiuent forehead nnd su|>erriliury rid^aw omlnibl with 
the comjtiiratively small face of the chiM. The previous 
birth of a hytlnx-ejthalic iiifunt, ami comfwiratively feebie 
fietnl luoveriieiita, are eorroljorative circumhtauceti. 

In breech i>reseniiui(mH (they occur one out of tive in hydro- 
ceplialic caHes) the diairntttiii} iis more doubtful. Nothing 
wrong is suspected, usually, until the IxkIv i» l>orn ; then 
there is delay, an unusual resistance — a sort of elastic, 
resilient resistance — on making traction upon the tody 

Fio.218. 




Ijibur impudutl by hyilriiccpliultiii. 



The body maif be well nourished, but frequently \b flmall 
and enuu-iate<l. The uterine tumor is of larger size than 
usual alwve the pubes, owing to it* containing the distended 
cranium. 

ProijnimK — The chief daugen* lo the inotlier are uterine 
rii[)ture ; e\hniiF>tion ; laceratioi], contuniim, etc., of »of) parts, 
^vith «ulH<e<|iictit ulceratiouH and fifltulie ; all preventiihie, in 
great nieasurc, by timely OiietiHtnuce of the olwlotriciun. The 



480 



MULTIPLE PREGNANCY. 



child generally dies, either l>efare, during, or shortly a^ior 
delivery. Exceptions jjossihle. 

Trfatumul, — lu head presentations, aspirate, or tap skull 
with tnx-ar and oaimla to It-nsen its size, when this is nbeolulely 
rei{uired. Climes of moilenite enlargement niiiy Ite delivered 
stKjtitaneouHly» but it it* hetter not to risk life of mother by- 
delay ibr the wike of a child whose survival at best is cxtreniely 
dubious. AAer puncture, and reduction of size of head, it 
may \)e jMMlh/e to extract by forcei)8, but tliey are nearly sure 
to slip otV during traction it' the head be very large. Then 
either the cephalotrilje or crani<x'laj*t may l>e used ; or the 
child may l>e turned and tieliverwl by the feet, e«|>eeial care 
and gentleness being necessary to avoid rupture of the womb. 

Fig. 2K». 




Enc«phiilocyto. (From Hekoott.) 

In broeoh preKontations, puncture of the aften'oniin^ head 
may l»e made liehind the ear, or through the »xxii)Ut, or 
through the orbit, or roof of the mouth ; or the spinal cord 
may Iw o|RMieil ani a wire or a metal catheter paa^eil through 
it to the bruin, and the Huid thuji <lniwn off. 



Enckpualoc'ELE, — Associated with, though at other timet 



ASCiTES, TYMPAMTES, ETC 



481 



inrlepcndent of, rt)ngenit«l hytirui'ophulus, niay l>e un u(t'»i- 
nmlntioi) of cephalic Hukl nuteidc the crauium uuderiieath 
the si^ailp, forming a tumor, ineij^nifirant in sixe, or as large 
as a fu^tal head, wlume nivity may, or may not, iomiuuuicate 
with that of the rTiiniuni. It i,s attached to the head In* a |K*di- 
ele. uud <Hjii8tituleH a fto-called eiKv|)haItjeeh\ (S^e Fig. 24V*, 
jMige 4js0. ) Fortunately, sucli tnmor^ are nnwil ntWn attaehetl 
cither to the frniilal or (K-eipital [nile of the ftelal hviui, atul 
henee are less linlde to interfere meehanieally with delivery 
timn when placed eWwhere. The hones of the eranium are 
also usually wofter and more yielding. Puiiettire of the sac 
and evacuation of its flui<l will remedy any mechanical inter- 
ference with delivery that may arirfe. 

AN'KNcKPiiALrs.^A not niironimon nionBiropity in which 
the brain is deficient or rudimenTnrv ; the iipf)er jmrt of the 
cranium iti ahsent, leaving the lmi*e of the skull witliout himy 
cttvering ; sometimes arrwt of development in t^jiinal colunni 
and ftpinnl cord. Often awHK-iated with |wily hydra nmitw. 
ShonUiers may Ik» very broad and ohMrurt delivery*. Diag- 
nofii* sometimes mmle by finger touching the selfa inreica, 
covered by wift tiwne^ in Imw of hkull, which may present at 
centre of |)elvia. Child either U)rn dead or dies H>on after 
birth. In case operative asii^tnuce be necenary, pcrtbrm 
embryotomy. 

AsriTEH, TYMrANTTES. DiBTEXTION OK TUE FrINARY 

ni.Aur^Eit, HviiROTHOKAX, IlYDRONKriiROffia, an<l various 
other jiathological enlargements on the part of the child, may 
(xtti^tionally lead to dilbcult labor and re<piire ojwrative inter- 
ference. (See Fig. 2o(). page 4S2.) They are extremely diffi- 
cult to diagmxiticate befori* delivery. The diagutfria ehierty 
rejits upon the excbwon of more ct>mm(»n mn>*eH of mechanical 
ol structiou, and (in the case of gaseous or litjuid dit«tenti<in 
of cjivitiess etc) on (he ppritigij^ reifilleyd rem/*taucf re«*ugni2- 
able when traction is made on the presenting or extrndetl fo'tal 
fwirts. Liipiid or gaseouf utxnmulntion/* are to be relieved by 
careful puncture, preferably by a.'*pirali(m, if the chihl l)e 
living. Fortv|iH, version, and exceptionally eud>ryotomy, may 
arterwnnl be re<iuire<i. 



SI 



482 



MULTIPLE PREGNANCY, 



Large 8izK OF thk Chim). Pkemature Ossiru'AxioN 
OF THE Cranial Bones. — In over-long jiregDancies (those 
of lOi. IT, iw VI lunar inonlhs) the child is apt to l>e far 
above the uaual size and weight, lustemi of weighiug stsven 



Fio. •iSts. 




Dliteotion of urtnary bladder uf the fa'tua. 

or eight pounds (the average), it may reaoh tweire, fifteen, or 
even more, and th«iugh the increjise is di^lrihuted tiver the 
whole IhmIv, the degree of cranial enlargement e*j)ecially may 
MUisiderablv impede delivery, and a (vrtain amount of diffi- 
culty may even attend extnu-tiou of tho f-iioul<k*i's and IkkIv. 
In carefully mensurinjr the c-r:uiinm of n child weighinj^ thir- 
teen and a half |K>uniU iuuut'ilinudy after hirtli, I found all 
of itrf diameters nearly an inch alwve the avenure length. 
8uch iid'anta are usually males. In wcll-firmc<! and pood- 
gizcfi jielvess delivery may be aocomplished by I'orcei*, vemion, 
or symphyseotomy. In very extreme ca.se8 craniotomy, or, if 
the child be alive, C^U'sarean i^ei'tion. niuy hci'otm^ a poH^ible 
neceaaity. In delivery of the NhIv. traction and nmnual 
aid in furthering the normal meehauiBm of labor will usually 
suffice. 



Premati-re Ossification of the Cranium sufficieDt to 
interfere with mouldinfr of the head, thus producing dystocia 
(difficult lalK>r), is very rare. 

DiftffmisU by complete closure of the fontanelles and unyield- 
ing reaistunee of tlie LK>nes to presturo of examining tiuger. 




LABOR: TEDIOUS, POWEnLESS, PRECIPITATE. 483 



Treatinmt — Forc'e|)s, if required ; [xjaaljly |)erforation of 
tbe ekull. or alKlumiiml tiectiou. lu Hunie oasoH sympbyiicotuioy 
may t)e lulvisahlc. 



CHAPTER XXIX, 

TKDIOUa LABOR (m'STOriA) — POWKRLEH8 LABOR — PRECIPI- 
TATE LABOR. 



Tedious Labor u-allt**! uiso •'Linoerin(;," "TARnv," 
*• pROTRA(TET>," and '• rKrn.t)N(iKiJ." I — Th(*e terms refor 
to iim(\ hilt the (lurniitm of liilwr variw so widely within the 
liniilji of noriuality, lliat it alone 18 not sutfirient to indiciite 
the tt'cliiUKil and j)ra<'tic«l meaning of "tedious" deliveries, 
(-'ertuin other plienonieniL inenlioniHl Iwlow under the head of 
**»Sy"'/''<'wi^" are ntH'e*tary, before any eaw <^\\\ i)e !*et dowu 
in this cjitegory. Recent authors have alnior*t al)andone<i the 
tenn *' ietlionn Itihor." and include euch cat^ci* under tbe cap- 
tion of ** DijMlociti," meaning tHJfi^ttH or oljelructe<l ialwr. 

(ViMwvi. — The very nurnerouB uonditions liable to produce 
te<iiows labor may be bnmdly coniprir*ed in two Vi^U : 1st, 
C'ondilioni* impairing the natural forces of lalior; antl, 2d 
MecJmuivfif imjit'dimeutji to delivery. IV)tb kinds of coudilioxia 
may, and neeeK«arily often do, etiexiht. 

Tlie inechaiiicjil im|)edimentH refer either to tht^ mother or 
to the chitd. Following tbe elasfiification of Simpson, we 
have, therefore^ altogether : (I) abnormal /w«'<t; (2^ abnor* 
mnl ftnusarfe ; (I?) abitonnal poAjirnfjrr. 

Ahnoniutfitiva af Powt't. — The mntn foree by which the child 
is e.\j)ellKl is that of ttterhif iwttifrarfiini. This may be im- 
pairotl in various ways. In sctme cases the pains are weak 
muf intjirietit from the hnjininiuj — a contlition t)f things quite 
(litfereal from weak \Mi\us (olUncintj long-reiK^atod stmmj onet 
an<i produeeii l»y uterine exhaustion. Or. again, the pains 
may have been moderately stnmg or nnrmal at lir^, and then 
lajirie into weaknen** hiter. but again mihnut uterine exhaus- 
tjim from prolongeil cinirt. The ntmen oi I hiis y;nmary iueffi- 



484 LABOR: TKDIOVS, POWERLESS, PRECIPITATM. 



cieuoy of uterine TOUtrot^Uons are; ovt-rdwleution of the 
womb fnuu |)Iunil prvjniuacv or pt)lyhyiiram[iio8 ; dbteatioQ 
of iho hhuidtT or reotum ; oblujuilies and diKplaceiiieuts of 
the uleniti ; tliiuuing of the uterine \m\\U rctiiilting frmu fre- 
(luent :ind qiiirkly rej»ented lnlx»rs<, or fruni degeneration of 
the uterine tis.sut*'; prwofiouH or advanced tige ; general de- 
bility or feebleuesfl of the WDinan from previous diseasee, 
euervatinjg^ luiliilts heat of clinmte* or of wawm. or the air of 
a i*uperheaied room ; exhaustion of the woman from hemor- 
rhage or trom lack of sleep or ftHxI. I'teriue action is some- 
times ineHieieiit from unt^mia. and when there ie morbid ad- 
hesion liet ween the fatal meniltrane8and uterine wall. iSIental 
emotions: fear, grief, ^l^rpri^e, anxiety, disippointmenl, and 
the prei*enee of oH'eusive j)erfH>iis or thincs will produce it. 
Theae hwt may dej)end ii|>on idio^yucrasy or unaeoiuDtable 
pen»onal antipathies. It pliould he e«peeially notetl that the 
lingering ease^ now tleiii<'ril>e<i are charaeteri»e<l by iurjficiertt 
patHf* frimi the be^imiwg of labor; hence sometimee called 
yrimnrtf hwrfia. 

Another and ditierent clut« of cases are thot^ iu which 
labor pains have been normally strong, or even stronger than 
nornuil, and njtmvard heeomc feeble and less frequent, or 
ceaiH? altou^ellicr. In thej^e the womb become** more or lew 
passive fnun muscular exhauHtinn on a<*<*ouiit of overwork ; 
it is srfondtirtf htrriia. The organ gin^ily needn reet. There 
may or may not be mechanical oht<triietion to deliver}'. Tbid 
patf^ive womb in *i(tft ami p/iaUf : the different jwirls of the 
child may be ta^i/ij Jflt by alMluniiaal pal|«lion. 

A Ihint set of caeteH are th(it»e in which the normal iuter- 
miltent lalwr pains hft\'e grown feeble or ceaMxl altogether, 
while the wond>, ioHlead of being »)i\ and relaxnl. i^ in a 
condition of coidinnou* nfjidittj: it» niuiK^'ular walls remain 
harti and cloi*ely embra^'e the child with a prtftiateni 8|iafl> 
modic gra»(>. This cimdition is ^jmken of a» " timir omitrac*' 
tion" and ** utcritif tfUntim.'" The womb feels like a mlid 
tumor: the ditt'crent partn (»f the child rantiot be recognized 
by paJ|mtinu tlinuigh it.«* rigid walls. It is ui^ually crt»W by 
ftime werlmrticft/ oh/ttnifiioit and eon.seijUent uterinf exhan)*tion 
aHer prolonge<l and unttnec4'j*iifitf gtromj cu^pitUh'r paimf, Krgot 
may prtnluee it In some (but not in all) of the^ cases the 
tliiuning of the lower uterine segment and thickeuiug of the 




TKOIOUS LABOR, 485 

upper reg;ioii, sepuraUHl l»v the *' rttrtuiiou rttiff of Ramir* fas 
previuuHlv duJcriltiHl ia the I'hapter un " Rupture of the 
Uterus"), may he tliscovered l»y [mlpatiou. 

The SiX'Jilled vwae^ of '* irtanoitl Jalrifoiin ronjftrirtion of tht 
vierttti" »upixwe<i to be au irregular, (partial, or spasmodic 
contrnrtinn of certJiin more or U':*s central rircuUir hamls of 
mufliular (ihr«*. and re?*einhliug the " hffur'<jlnJiK ronintction^* 
olwervfti (Inrin;^ the third ;ita*re of lal>or, is probnhly uothiog 
more than tetauio tH>nsirirtiou of Baudl's ring. It is so ex- 
ceedinjj^ly rare that its o<xrurrenre hits h(?cn deniei! Iiv some, 
while others affirm they have rliuically demonstrated its ex- 
istence l»v feeling the eoiihtriction band like a '* mttaUic ring " 
or "rirc/f of iron,'* with the hand in the uterus. 

8till another abnornnilicy of pott'er eoneists in the pains 
beiuj( rxcejiifiirfif jtaiiiful jtti'iuif. Usually due to exalted uerv- 
oun HfttJtihifitrf or unusual stt^rrfttiltiiittj u> suH'eriiig. Some iften 
bear yinin 1)6114^ than others; so with women in lalnir — !>t)me 
tolerate the snrtV.ring without mneh amiplaint, others are ex- 
ctifirtively ttenHitive. 

in 8omp the extreme pain has been flscrilxnl to rheumatism 
of the uterine wall, or to parenehynuitouri metritis following a 
blow or !*ome other traumatic injury before lab<»r. 

Again* either with or witliout any abnormality of the uterine 
contractions, lah<»r u»ay Ife im|»e<Jed by i*ome abnormality in 
the <*onirartionM of thr abilominai t/vj/A and til/iphi'tti^in — in the 
straining or *' be:iri rig-down " eilbrts, constitutini: the i*ertmd- 
anj forcrjt of parturiti<m. This may occvir in any fiL«e where 
the woman iis unable to take* in a long breath and hold it lon^ 
enough to acconipli.ib the act of straining, aii in disenses of 
the lungis pleura, heart, or abdomen, or any other condition 
pnxlucing dyHpntea. Hronchocele. olienity, ascites, <let'ormitiee 
ot* chest and spine, sometimes act in this way. Feeble ab- 
dominal contriulions alw arise from the woman lifTneff beiui? 
enfeebled by previous disease, or exhausted from previous 
prolonged straining efforts ; or, a^^aiu, excc-sr^vc sutt'ering 
may cause the woman to voluntarily refrain from bearing 

AbnormafUffH of the Pamnvjr. — The mechanical iuif)edimei)tB 
U> delivery referable to faults in the fiarturient cjiual from 
which teiLious labor may result are numerous, embracing, of 
course, every kiml and degree of ulistruction, such as small- 



LABOR: TEDIOUS, POWERLESS, PRECIPITATE. 



Deaa, <leformity, and abuartnal growths of the pelvis ; ao«i 
iTwiptAnce, rigidity, rloforiuity, and abnormal growths of the 
wjft parU, etc. 

AfntornuifiiffM of the PttHneu^rr. — The iDtM-hniticul ini|M><li- 
nieut8 0D the jmrt of the i-hihl are its oviT-large si/^, nialpre- 
seutation, dkturhed uie<*haui8[ii, [tathohtgical growths, l(M'ke<l 
twiuis etc. 

Prof}rio»U avd Danger of Tnlious Labor. — The first iitageof 
labor, hefore rupture of the menihrnaes, may be grojidy pro- 
longed, even for «»veral (hiy.s. without any nt'cciwiriitf s^Tutui*. 
cnnsieqnenpes to either mother orehihl. Kxeeptious, however, 
occur. The continuance of anxiety, hutteriug, aitd plivt^iral 
effort, with coDsequent I»)sta of sleep ami iualiility to digei^t 
and uj^imilate foo<l, if hing proU'aete<l» attvaijii entail a Unh'dity 
to uervotm exhaustion that cannot he regarded withont ap 
prehcu^iou in any case. Before rupture the waters act as ii 
cushion Uetweeu wonih ami child, thus protecting both from 
injuriouH pref**ure. PriT^^urt! n|K>n the funi.-;. and oht^trurtion 
to the [ilucental circulation, i*uch a?* may occur when the womb 
y long eoutracted round and in cJum; contact with the child, 
uiv also ifhviated. 

During the second Ptage, when the womh dort^ contract 
poweHViUy and iu cli>se contact with the infant ; whtm the 
placental uirculatiou, therefore, m. or may be, iKirtially inter- 
fered with ; and when ibe soft |mrlH of the mother, liolh the 
uterus anti other parts below, are neci-ivjirily subjected to great 
pressure, the rt'wuUs of prolongation of tlie lalwr liecome far 
more serious. S\v-clli[ig, oedema, intlanuuation, with ^^ubK^ 
quenl sloughing and fij*tul;e, may occur : the child niny die 
from continueti eom[ir<.^iiMtH» of ii:J skull, (i>nl, or placenta ; 
and general Hvmi»tom«of exliaustion and cxjlla|»ie take place. 
from which the woman, if not promptly delivered, nuiy die 
on the spot, or Hiccumb aHerward from |>o»)t-partal bemor- 
rhnge, puerperal inflammation, seplicteniia. etc 

Every cast*, therefore, of actual or tm]>ending leiliimB lalmr 
should excite apprehension for the womau'rt safety, iiicreai*ing 
in degree according to the extent to which the symp((>ms have 
protrn\st;(:d, and tJie estimated difficulty of prompt delivery. 
Witli timely assistance safety may of\en he as!*ured, while 
delay may render recovery imiHjpsiblc. 

Spnptmiu^ — These, be It Doted i»nce for all, usually begin 



TEDIOUS LABOR. 



487 



moderately, but increase in varying degrees uf rajiitlity with 

(lehiy. 

Ill ai8C8 of j/rimurtf uieriiie inertia the jjaios (oB we liave 
sttitl before) are UBually incfficieut /rom the btgimiiit^. These 
caees, iinlebs vcnj iiiui'h pr(.)lnnjL(etl, are tioi a(.rnni|>auie(l with 
MeriouH ijtiiend ^jviupt^mis. Ai( u nd*', there is no ^'rent fre- 
qiieucy uud feehleut'R* of pulse, no nipid respiration, no l»eat 
of Mu, uo fever, no general exhau.stion ; in futt. there hai$ 
tx-en no violent physiinil ett'ort — no strong' pains — to pnnlure 
fatij:uo and ex|>en(liture of nervous force. Lops of sleep, 
laek of UkmI, arid anxiety, etc., umy, Jiowever, cvtHtuaUy pro- 
duce it in vtiy protracted cui>«9. 

In cases of urcomlartj utrritie inertia the |)aiD8 have com- 
niouly hegun uorinnlly. and normally iucreat'ed in Htrength, 
fre<|Ufii*'v. nnd duration, or ihoy may have excee<le<i the 
miriiiid limit in tlic^- rc^prcU*. IJoth wondi nnd woman have 
UNUidly labored hard and (more or lej^n) lonv'. but tlie paius, 
thoijirh rt!roug» hiivi- ^lill been n/atiitly inefficient^ — i. f., they 
have been innutlicieot to (»vert'ome (he exij^iing resistance nn<l 
accomplish delivery. There iio>v apj)ear ^^ymplonls indicating 
ej'hau^tion of the womb, viz.: the pains become irrrgtihr in 
their recurrence^ i*horter in duration, moir j'eM\ nnd /c^jt frc' 
qui'jit. Eventually they may Htop altotrether. The nteruK is 
worn out In' prohmt^ed etfort. lis relaxation becomes ho com- 
plete tluil ilu^ diHtrciil parts of the child may be felt by nlv 
dominal [Kdjuitioii thrtm^di the now inert uterine wall. 

A ^ti'OHii .■H'l of symptoms are th<»se inilicatinir t\r liaii.it ion of 
thf uiijiiaii, viz.: increasetl feebleness and frequency of pulw* ; 
coate<l tongue, lH*co»)in^ later ilry ami discolored ; rapid 
brcflthinj:; vomiting; dejected countenance; ^estle^snes8, do- 
Bpondeucy, irritable teinf)er, peevishnes*, wilfulness drilling 
on later (if not relieved) into delirium and despair. 

A thin! K't of symptoms — usually most pronounced when 
Inlwir lias a'lvan**etl to the second stage — nre thnse due to com- 
jiinu'inff iiiJiammatiuTi in thf gfjft /Ktrfj* from |)roloMged presbure 
a^'aiust them of the child, viz. : twelfiug, tetttiervntu, pain, heaU 
hick' of tnoifttun; in the vnjjina, utrrns, vulva, etc. and 
dcinonstrnted by digital exnTiiination. together with rcdtirM, 
/iHilltjj, or other abnormal disc'olornl.i(m demonfitrated by in- 
spection. 

It should l>e especially noted that these three sete of syrop- 



Ua lAliOU: TEIifOVS, POWERLESS, PRECTPJTATE. 



turns may exist i» fvcry nhaite of dnjrfe: they may W only 
!<li;rlit or very nruiiuuiit'e<l. No riii^e nhoiiUl Ik* allimfil to 
|irnj?ri^« Trtun the slitrhter ami wirlicr syniittoiuf oi* exbautf- 
timi to thi' lattT autl luoix* jjrave uuc:* williuut |»ronipt mi'ttis- 
ur«>s of H.'«ist«n<*e aiul relitif. 

Ill till* noi-Mt vianv^, iMfitead of the womb reiuniiuii^ etott hikI 
inert, and while interniitlent pains iimy have rntiirh( rfrtvVf/, 
thi^ uttTUs iw Ituiii ami 8pai<ruwii('ally cuntnirlrd nyaini ihe 
rhifd, KuJ rt'tmiiua m C4}ntiumnmftf (ao-calletl *• Uterine 
tetiinus"). Hero the syuij»touis indi<iLtiii^ vxhaiuffion of the 
^"ituintt are iiuich more pronouiu*e4l than when^ the iiteniA m 
ill a sffile tkf relaxation ami inertia. Furthermore, iu tike 
ri^fid tvutrnrtioa <t>nditiou the woiuh is fetifirr tu thr touch i 
in the inertia raw* it is not uj*ually so. S)me nieehanii-al olv 
BtnictioTi — eitlier fd'tnl or muterual — conimoidy pn*ht*nt. as 
intlieaie<J liy lack of projrre:* in dttseent, imn»ohility un<l 
Hwellinjr of the prec^nitin;; \ri\rU or by aeluul demotibtraliou 
of existing ini]XMliment. 

DififfiioitM. — The roinbiantioii of symptoms juBt stated, even 
ill tlieir early and hiighter munifeislutioi)?, e«)*et'tally when 
eotiple*! with prolonireil duraiion ami lack (»f pro^-n-hrt in the 
lii})or. and evident eiiiute.'K ot' niei'hanienj liinderunec to de- 
livery, can leave no |M>s.sibli' room fur ilonht. Other condi- 
tion» leading to eej*fation of lalmr (Kiinn. fnH)ueiit luul feeble 
puUe, ('olla|ist\ such ixs, e. fj., rupture of the womb and hemttr- 
rhape^ have a different history, and the symptoins are i^udden, 
instead of jfraduab in their appnmeh. 

Ti'entmrni, — The main element of treatment is to trpal the 
en«J ("'ir/v. l)efore the Hymptonm have proirreH»ed l>eyoni| re- 
covery. The indications are, in the bejrinninjr, to ('»>rreet or 
remove existiniif cau^fti of uterine inertia and exisilinfr me- 
chanical ini|)ediiiuMit.'* to delivery. Wlien manual or instru- 
mental delivery is n^ipiired, the ii|i«»nmon phonld Ih^ bejrun, if 
prai'ticable. U'fore, or at leai*t a^ kiuu oh, the tEyuiptouifl of 
ttntiouH laU»r htfjiit. 

When the |ioini* have Iteen iitetticient and feeble from the 
Iketfinain^' ( priumnj uterine inertia;, the c;uusei4 that lead to it 
tnurit \¥f. removed. 

Iu ever>' case ascertain that the Madder and rectum are 
empty. If they are uut, a catheter and purgative enemata 
tniiM be used. 




TFA)!OVS LAliOlL 

fimBsive tli^lentiuu of the womli fmrii ^Iropsy of the 
ftlHliOIt requires evm-iiatioii uf the Hiiid hy rupture of the 
raetuliraneir ; <listentiun frum twins, delivery hy Ibrcepe or 
ver-iioti. 

The* pffect of vi*tleiit im^ntiil emotion onn scarcely l»e 
nnielioratetl elst than by nmrnl iwrsuasion, (piift vx^t, and 
perhH])fi a tN)nipoe*injr dose of valerian tolix. valerianat. aninuin. 
gtt. XX). or one draehui of the tJd, extr. of valerian. Any 
offensive person or thinj^ should he removed. 

L'terine tWddeiiess from el ee pieman ess due I » a firolonjzed. 
first sfta^^e of lainir re<|uire:s a full diRW of nuir]>hia (gr. I ), or 
of chloral hydrate ((jr. xx). The «ime renuilicis may Ik* Ur^ed 
with ^<hh1 refiilta in e«sc«» where llie |»ains l>eoome feehle from 
tilt' woman having endure<i ox(!et«ive Hutferin^ — the ])ain8 
havinjjf heen extremely ^'painful pain??." The c*ittM' of the 
extreme (ittin should lie found and, if j>ot«ildCi removed, l>e- 
Ibre the anoilyue in tJtken. The Hutferinjr may be mitigated 
by a little ether iidmlfd jusft m the labor |)aiu8 begin. 

Ijiteral obliquititt* of ihc uleru:? may In* cornH!t<'<l by a 
fniirtT hixiki'd into the r»s, while pressure in niaile in the ri^'^ht 
(lireciioii n[M>M the fnndii.s. The woinnii .^honld lie on th<' .side 
op|M*tiite that to whieh the fundus is directed, h> that tlie 
latter fnlls ?*traiirht by its own weight. 

rmisual resistance of '• tou^h membrancfi,** or ndhcfdon of 
the deridua to the uterine wall, mu.n be remeiiied, rei*|»ec- 
tively, by rupture of the sac, or by breaking up the adhesions 
with a finger. 

A feeble, debiiitatwi woman must have foo(i Cmilk is best"), 
antl a moderate quantity of wine or alcoholic stimulant, ^'ivea 
cautiously in 8niall quantities at ithort inten'aln. 

When the cnut*ft§ have l»een removed, the lazy actions of 
the uterus may be stinmlated into more vif^or<»ns contnictious 
by a wann vajrinal douche, by inlrodncinfr a Ixmpie into the 
uteni:», by dilatinjr the cenix with Barnes'!? water-baps and 
by the internal administration of mdphate of quinine in do^« 
of ]() or 15^nu[i8. The use of erg(»t is extremely (piestion- 
able. It should never be ;riven in ])rimipara\ nor in eases of 
meehanii-nl obstruction. If ^iven at all. it plumid oidy Ik* in 
small d<jj*es of 5 or 10 drojw of the Huid extract every half 
h(»ur, and Htop|>ed hh mmmi iia uterine contractionH have iK-en 
remforced. In ca*es« where the inefficient pains have ci»u- 



490 LABOR: TEDIOUS, POWERLESS, PREaPlTATE. 



tinued long eiiou^^h ti> proiluce exImiiHtion of the woman, or 

annmt'iwiutj exhuitslioii. ilelivery i*1i(»m1iI l>e a-ssistMi l»y r<»rtt*|)g 
or l»y wliHk'ViT oiK^nitivi* iiR'UHiiri's tliu t*lu^'i* **i' Inlutr ami 
riiittin' (if the uisi' will luhiiit. 

Ill futiuri of Heruiitiiinj uU'rine inrrtia, hi uhich the wonil> 
and wotimii ure extiauHted fit»iii fruitlet« prolod^c-il effort, the 
lifcHt treiitiiKMit if* t<» rentore th*» flH^jjiiin |X)wor8 h\ muutl nlft'p 
[)r<j<liuvd Ity J'uJl doifo^ of op'nim^ morpliiu, or chlonil. Hy aieep 
the nervous cnertrit'tt are roHturt^d^ iIh' pniiif* art* rene>Ye»l, niid 
iioiv delivery Hhoiild he hatiteiie<l hy foreeph; or other operative 
niL-anures tho fxislin;! ol^tnictiuii may rail tor. If delivery 
hy an o[>eration sluiulil lie afM-onipliKheil while the uteruH re- 
muinni Mjtj't, jtfittlilt and inerij po8t-|iartai hanorrhogc would l»e 
alriHiat sure to follow. 

In cases oi'" tonic evutrartion,** in whii-h the womb retraots 
down ii[»oii its content** with contiuue<l [lersiiJlent rigidity, and 
the woman b p-reatly exhausted, (fi'firpnj at ovcf^ witlioul auy 
delay, is the oidy proper course to pursue, the method of pra- 
(vediii^ de]KMnlitit:, of course, UfHin the kind and degree of 
existing ohstructiou. 



PoWKHiais.-* LAnon i»riu'iiciilly meant* nothnip more or 
than the Inrt stage of teiliou?' liiUir, |)rfvi<tUHly deserilicd. 
mwers of the wimifin and of her uteruH are itunpletely ex- 
hausted. Sueh eaM-ti shuuld never he |*rmitteil to occur ; 
and scarcely cA'er would if '*t«JiouH" c-awt* were promptly 
delivenMl liefore Lliey l»ecoine too far advanced, as above rec- 
ommended. (iSee •'Tedinu8 Ijiltor/' imgw 48.S-4t)0.) 



^fl 



Precipitate Labor m one in whi< h tlie child ib delivered 
with unusual rapi^iity. It is of cdinpnrativdy infrequent 
wcurreiice. The infant may l»e ex|xdie(i unexpcrttiily, while 
the wonmu in Htanding or walking, aud, as Kimetimes un- 
uleaHantly hnp|ien8. in puhljc ]»la<*es ; or while she is al stooL 
The child !miy he injurc<i by falling from the mother — such 
(rasett sometime*' leading to unde*terved MiS|»icioi:<» of infanti- 
cide. Thf umhilical cord may l>e ruptured in its eontinuity, 
or torn out at its junction with the diiv<*1. but the bloodvca^ls 
ui*ually contrart and prevent hemorrhH^ro. The child may 
he horn in it.'^ unbroken membrnnes, and drownwl in the 
liquor amnii. NumerouH alleged dangers to the mother may 





PRECIPITATK LAUOn. 



491 



result from pro<'i|/!lait' lalwir ; Imt their orcurn^iKV is, on tlu; 
whole, i.'xivj>ti<nuil. Thf,st' ure : iiifrlia jjimI |mj«t-|>artjil Iteiii- 
orrlm^e fr<tiu sinlden ern[it\'inyj of the wntnU; inversion of tho 
uterus; t<yiia>[>e I'roiu iilirupt rt^iluction of ulKlijiiiitml (linleii- 
tion ; rupture of the uterus, larerution «)f it,-^ (vrvix, aud of 
the [>eriiii'Uin ut vii^iim : (>rm-t(leiiUii of the woiiih. 

VauA'Si. — Unusually liirjj:^ nize of the pelvU ( pelvia axjua- 
hilit^T jusrif-niujor). LuuHnal laxity and iliniininhoW rosisl- 
auce of tile i^\\\\ |iurt>i, as in r;u5L'd of* unt;ure»l fxtensivi* lacora- 
tioii of cervix tUeri, the result of a jirevi*Hjs lalxtr. Kxressivc 
i^iixvv and frequeiu'V »»f ihe |>aiii(s. and of rellex eontraetiou of 
the abiloniiini] wall^ and dia{>hraL,qii, <,^^enerully <lae to peculiar 
teuipt^ramenl or luTvotw exeilalnlity of the woman. 

SjfmploviA. — The pains rome on with little or no waruio^, 
and arp l>earin|: ilown in eharaoter from the l>e*;inning, 
quickly suetvedin;; each other, aud nipidly [)ro;;ivssin^^ to very 
great intenhlty. In a lar^je |>elvis, or when the child is very 
Hmall. lalK)r naiy U*. terntinuled in a few mhiulets, without any 
necrn-ttitiftj over-violent pjtins. Violfut pains and a larj:e ]»el- 
virt nmy, however, coexi.sl. The child may Iw horn durinj^ 
sleep, the wonmn dreamin;^ she hail ctdie. Intensity of sutfer- 
\u^^ on the other hand, may [iroiluce transient mania. 

7Vert/mnt? should l»e preventive in women who have previ- 
ously had precipitate hihor. It i« liable to re<-ur — (vrlainly 
Bt» when tiic iK'lvis is overiarj^e. The woman siiould kw*p 
her room during the husi week of pregnancy, and go to lied 
on the tinit indiealit>n of lalH^r pains, a eonipt^tent iiurne 
having; heen previously provided. 

Durinnr lahur, aiui^lheaia constitute* the readiest nieait? of 
lessening uiitlue violenee of the |>»infi. Opium internally ; 
morphia ^ven hy|)Oilermienlly, or hy rectal 8up|x»*itories, 
when there m time for them u> a(*t. Tepid eruMnaiii, to wash 
out the lK>wel, and an niHh>minnl handnt^e have a s<M>lhin;; 
influence to some extent. The wonum niusi avoid hearing' 
down, as fnr as |)osHihle, hy eryintr out, in&te^id of holdin;: in 
her hrwith durinij a [miti ; an<l everythinjj likely to increase 
utt^rine eoulraetion nnist be avoidetl. I'nM'iiientia nniy re- 
quire a T-bandajye over the vulva, an n^»erture l>ciug made in 
it throu)^h which the cliild may l>e Imro. 



492 



PrrFIClfLT LAJBOR. 



CHAPTER XXX 



DIFFICULT LA BOR — DYKTOtI A - 
Tin: MATKKNAl 



FROM ABN0RMAL1T1K8 OF 
OUCANH. 



I)f.koumitii» of the ;W)'w have alr<*a*ly hwn consulere*! 
(Chapter XXII., imge'iHti). The |>rtf>t:nil chajHer n-tera to 
ftl>norimil romlitious of the t<i>jt /Mirtft |>rodufUig tue<.*han)cal 
ohrttnu'tiiiii in lht> parturient c^aiuil. 

Ill *\\i\U* noniifd lulxirH there art' altiat/a two Imrriers by 
which tk'livery of the ciiiJd b more or /rw» iniptHlott ; th«*e are 
the OH Hft'ri ami llie of t^mji/in'. The deyr** to which tliese 
interfere with ilelivery hirji^cly clo{)eiuls ii|x)ii titc eiue with 
whi<:h thp two o(N.>ninp* diluto. Hence a ri'jid o« and cervix 
uUri. and a riifitl fit^rhieuin, which refuse to dilate liefore the 
prewiirc of tlie prwjenliii*r pari, may ihup ul)Klruct delivery. 

Jiitjlffittj rif tin' Oft uttri in either itjutttminfic or oiydnir. Spajt- 
nifHlic njt(i4lity ow^un* iu Li^dily ucrvous and emtttiiHial prinii- 
{nine nitiwt fre'iuently ; ur may Ik* due to premature rupture 
of tlw inf*mliniuoi* ; or to prematurity of tlie lalM>r, in which 
last the tiHsncA of the ih and (vrvix have nut yet uiiderirone 
the Uftunl §ofteninir hy which their dihitiihility is inrretu»efl ; 
.^luivanccd age in priinijmne prc^Milfl il>e siuno wmdition ; the 
partii are It-rw **npple and dilale more slowly than in yonnger 
women. Aj^ain, in eimdiliims where tho prcsciuinir |>art of 
(he chih^-annot deHcend and fill up the <>h nteri Cih in narnjw 
|>elvi.s tir frxirtu preHentntion ) clitiitalion will lie plow. In mnni 
caseH of >r^/<7j*>iio'/fV ri«.'iditv n.ssocialed with an iiz/nijiinrwl bi 
i»f waters, lalK>r in delayed not ho nuK'h on account of 
ripditv it«elf, lut Ih»cjui8C of incHi'icnt jmins; that is U> 
if |>ain0 continue jrood and fitroiifi. abiKVt any case of S| 
modic rigidity will yield l>efore them. 

Trt*fibnfni of SjHittimttfir Hujiifih/. — ^When the niembraw 
are intact, time and |>atienc<? UHmilly remedy ilie ditticnlty ; 
Iiut in thi»(* ca*ics. qb in others where the niemhraiH* h 
ruptured, dilatation is preally expeilited by full <i<is* 
chloral liyilrnte. jrrs. xv, repeated every twenty minutes til 
two or three dos:v have been taken ; or, instearl of thi*, a fiilj 
dowMif niorpliia sulphate ( ^'r. 1 to ]) may l>o injected 
derinatioBlly. <'otijoined with the auodyue, a warm bath 





DEFORMITIES. 



49:5 



Jiip Imth of fifteen or twenty njiunt**8' liuralion, or a douihe 
of warm (iiut hot) water thrown ajjaiuijl the cervix fur a few 
minutee, contribute to relax the rij^dity. Artificial diJata- 



Fio. 2ai. 




Eloii|tal«d rervtx with procMentln <1urliiR Ubor. (BAtim) 



tion with the rniKei^j «»r witli Harnf^'.-* walrr-hajji*, is uf'r^rvirc 
in ruj*e8 where the nalural lia;: of waters ha.-* U-^'H preumturely 
ruptured and the cervix is iitretcbed tightly around tbe head. 



494 



DIFFICULT LAIiOR. 



Ill <>Aiws where the membranes remain t/nhroken artificia] 
(liliiUitiou u protmlily tiHelu?t.s or wurtie. 

Ot'ganir vitfiditij of iho os ami cervix uteri wx'urs from ibe 
development in the )Minj$ of fibrous oonni'ctive tirtsue. the 
result of chronic iuflamnmtiou, or ihe cervix ix iudurateii 
from cicfttricifti — sMwuHe*! "wvir" — linsue fullowintr former 
laoemtions, ami tbisi (still mure rnrelv) is lialilc to l>e accom- 
Moied with httiterirophic rhjntjaiiou of the (vrvix iiuU pro- 
la[iHuif. 

Trcitiment — Milder ^ra<]es of oryitnic rijriditr may yield 
to the remedieii jusi citeil for /t/nigmodie ca^eb. SbouUl the^e 
fail, uud the <.Hnulitions not admit of deluy, the rim of the 
external os may l>e inrkfd with h1mit--[iointed dciftKirs or a 
prohe-{>oiiite<l bistoury, so ae to make three or four notcbce, 
aUiut a quarter of an inch deep, at ^liffcrenl i>oint-i. Barnes's 
dilators nmy he used tijifr the incisions as well a^ hrjort; them. 
Alisolule antiseptic cleanliness must, of course, Ik? oliservefl. 

In ca»«* of bypertropbic clonpition of the cervix, with pro- 
la[K*us or procidentia (see Fig. 'I'jI, p'*ge 493) incisions and 
mcf-banical diUitalion will l»e ne<'<'fiKiry. Forrc|is may l>o 
used wben tbe jmrti^ an* Huthciently ojten. and delay IxH'omee 
liiu^lvimLble from iin[»endint; HvmntoniH of exbanstion. et<*, 
Oi-iuirean section ba» lieen atlvibed. and might Iv ju^titiable 
Diider very nrjjent circumstances. Wben gc^^taiion, coexist^ 
ing witb elonjurated cervix, is made out wwm enouj^'b, amputa- 
tion of tbe byitertropbietl neck may be done at the tbird 
month. It lines nitt nfc.riwtniy disturb pregnancy. 

UiriiniTV OF THK Fkrineitm. — Tbe structures at tbe 
va;^imil outlet* like tbvtse of tbe oc* uteri, mut^l dilate to tbe 
extent of three or four incbes in diameter In-fore the bead crni 
|«S8. The retjistance of a riipd |H^nueuni is more common in 
primipara', esiKwially in thoeo no longer youug. Actual 
rii^idity (except in c(w*y with onjauir chan^ren due to cica- 
tricial tissue ft»llo\vin>]r llie bealini; of former Inceralionsi is, 
however, more ap(Muviu iluin real. It ih llie imn-tr, not the 
pttAmttff — tbe pnhtit, not the prrinrttm — tluU are really at fault. 
It \» an every-day experience to see tbe bead come down to 
the perineum and Klop there, fM*rba|rs for itfvend hours. Tbe 
pains fall ttlT iitul iKTume wcjikt-r and les?^ frtipient. There 
nmv Im' do nifchatiii-;)! nli-iiicli- (<• ili-livtrv ln-Kidfn rcMHtant'e 




RIQXDITY OF THE PERTXEUM, 



495 



of the soft lyATia at iht? outlet. Tlte usiihI reason of this delay 
is that the woml) aii*J tfiu woiumi have been w> fur worn out 
by the prt're«Iitt<; juirW uf the l:iU>r that the little adilitiuiijil 
elfort iieccssjiry to force the eliihl thnm^^h the vu^nnal outlet 
is beyoiui their jiower. To use a figurative exjiresisiou, the 
ri\'']Hia[ico of tiie perineum is *'tbe last straw that brenks the 
caniel's back,'* 

Ti'cuimeut, — When the heail is thus arresletl at the inferior 
strait, and there is no oilier mechujiical olwtacle to delivery 
but rejiistuurt: of the (KTiueunj, the best method of Ire^ituienl 
in tlie Inri^rer luirubcr of cases is delivery by force|»fl. While 
true lliut ill a fcrtain number of ca^es delivery would, in due 
time, s|xinlaii*HHi«ly ueeur after some hours' further delay, 
provided the uterine inertia and freuernl exhaustion were uot 
exceeeive and there existed no aljsolute nieohanicnl obstnrlc 
to delivery, exix'rienee has, neverthele«N amply j)roved that 
the renuind ad<lilioiiaI delay is not to l>f liepemlol otu while 
delivery by foreeijs may be safely and often quite easily per- 
formed. The old maxim, "Meddlesome midwifery is bad," 
cannot be npplieti in these «u»os. Though delivery initjht in 
time spontaneously oeenr, the cbancc« of final and rapid re- 
c*>very, nik^r lalwr, are far less than when foreepe are applied 
MHthoui ilelay. 

In pla<t! of forcej*" — as under circunistanees where they 
cannot be obtained — delivery may be expe<lile<l by mannnl 
prfSHure ujMju the uterus (and thus ufion tlie breech of the 
child) throu^di the abdominal wall. 

Manual preitsure is simply a sntistitutc for uterine eoutmc- 
tion. It !nay be tised to reinforce feeble [>ains or replace 
ulfsent ones ; and must imitate them. esiKrially as reganla 
intermittencc, dumtion, and force, as nearly as ixitisible, ('<m»- 
plete expulKion nf (he child, by prewiure pn»|)erly applie*!, hna 
even been acconiplishe*! when the pains were entirely al>sent. 
It is a)>plied thus: The patient lying on her back, spread the 
palms <it' the hands out over the sidt^ and fundus of the 
womb, and when a pain begins make tirm prcj%*ure, while it 
lasts tlowmrard and imrhvar<f, in a line with the axis of the 
plane of the su|>erior strait. IvCAsen, and then stop preading, 
ns the pain goes off. If there l»e tto jtains, imitate them M 
nearly as |Mi8sible. If the wnuian lie u|>on her si<ie. one hiuid 
only can Ik; used (the lell, if she lie on the left side ; the right, 



496 



DIFFICULT LABOR, 



\ 



if CD the n^^bt) to make pressure on the fundus, while the 
utiier KuanLs the pro*;ri'sa of the pn-tit'iiting jMirt par itiginam. 

Manual prwi^ure uiuHt not be tmployaU of course, when the 
uterus ia very teuder ou prtitsure, nor when it is fl|msmo(lical]y 
coulraoteil round the child, uor when there \& auv mec]iaui<«i 
impediment to delivery. 

Sulphate of quinia. pn*. xv, may l»e given to reiuforee the 
]>nins ; food and slimuhiuU to relieve general exhauittion ; and 
ergot to secure firm retraction of the uterus wheu lalxir is 
over. 

ihrfanir rigidity of the ]>erineuni — cicatricial induration 
following healing of former la<*enitioiiH — may re<|uire digital 
dilatation, luid, very rarely, incision of the resisting tiatnes — 
^isiulotuy — tt« reeonunonded to prevent ru|>ture, <^^e paga 
380.) 

BwideH rewistanop of «« uirri and ]>firiitmm, which arc quite 
common, tliL* more rare forms of olistruction l>y the soil parti 
may next lie considered. Tliese are : 

8wKLLINO AND (I^DEMA OF THE ANTERIOR LiP OF THE 

WoMU, from its getting pinched between the bead and puhic 
symphysis. It mui<t he pushed up witli the finger ends, and 
held there for scvernl sucfesiiive pains, nnlil the head slip by 
it If wucfi fciwollen nnd ap|iearing at the vulva. «(? may oc- 
casionally tM'cnr, pimhiiig it up is impractieahle. Deliver the 
child by furce|js, or by whatever metliod may be necessary, 
without delay. 

I.MPERFOBATK HvMEN. — An aimyhitely imjierfonite hymen 
would j»revent impregnation ; uii apparently imi>erforate one 
may ctmtaiu a small, undisoovereil o|)eDing, large enough to 
admit einrant'e of »|>ermatozoids, and may thus atteru'ard 
ctmstitute an nlistruetion to deliver}'. The organ may be jjer- 
forated w ilh a visible round opening ( Inpiten aimulariit) ot 
with several mnall apertures {hymen rrihrifnnnin.). 

Ditujnoffi''. — By imf*ossibili!y of uitrotluditg finger, and by 
snliHeiiuent )n.s{>ei<liun of {larts. I'revioufl history of partial 
retention of menues. 

TrcatmcuL — Incision nmy very rarely Ik? retpiired. 



Atresia of the Vulva may he partial or complete, result 




CYSroCELE, 



497 



in;; from iuflammatoTT ndhpsion ; IietiliTij^ of iilcvrate*! snrfnwa 
fulluwiiif; traitiuntic iiijiin': or iiiflauinmttun attoiiiliug exau- 
theniiit;i» former lal>or», eti\ It may be cougenitiil. 

DiufjiKfififf, — By iiiH|HfCiion. 

Trcaimcnf. — Ol>striictioM usually overroine I>y spontaueous 
dilaLatioii during lal»or. Artificial liilalatiuu by teiiLi, ur 
Barnes's dilators, or cureful incision nlon^ the median line, 
while lahia are stretched laterally, may he necessary. 

<Kdema of Vi'LVA, when excessive, may re<juire numerous 

biniill |iu(icture,s for its relief^ always preceded and followed by 
anti^ptie cleanliuese. 

Atre-sia of Vaginal Canal may Im? cou^miial or ao- 
mtired; jtartia/ or cmnpf He. Non-con^nital cai*es are due to 
iudamniatur)' adher^ions foUowiDjjr injury of tbrnuT deliveries. 
pe;:4sarie.s, ami other traumatic causes ; or tu iutlatnmatiou of 
exanthemata and other conHtitutional discaiHW. Considemhle 
eurfncea may iHjtxjmu adhereut, or coD»trictiu|^ cicatricial hands 
atdy exist. 

i>UtgtumA, — By distal examination, or ocular ins{)ection 
ihrouj^h *i|>eculum. 

Ti'eaiment. — A rtificial dilatation by elastic water-bajra, 
lentit. etc. I)iiwection tlirou^di olwtructintr tiiwue with tinker, 
or Hnger-nail, liuring lalmr pains, "radiialU* cxe<'iited with 
care not to jwuetrate vesii*o- or nH'tt>-vaj;iiial walU. Shallow 
vertical incisions — loii»;itudinal scarifications — for cicatricial 
bands; and cjireful vertiivil incision of central Rcptuni of ad- 
herence iu bilateral union may be require*l. Finally, forceiw de- 
livery, to prevent prolon^e^l compn'Ssion of parts by frvtal head. 

VA<iiM8Mis (sfMismtxlic ci:>ntraclion of the vaccinal orifice 
or canal). aagtociatiMl with s[Musm of the levator ani mns(;le^ 
very rarely, may interfere with lal^Kjr and r«i|uiro forcejje or 
other artificial aid. 

Cystocele — Prolapse of Vesico-vaoxnal Wai-l — may 
l>e due to. or ajt»tx^iat^l with, retention of urine and vcflicnil 
di-leutiun, (See Fi;;. 2o2, ^mi^c 41t\) The pndnix^l wall 
prest^uts a tense, fluctuating tumor, more or lesH occludinij; the 
vajirina ; it may be forced down by advancing head, or evou 
ruptured. 
■ 33 



I 



498 



VIFFICVLT LABOR. 



Si/7nj)t.oms and DiufjnogU* — Kuowu existence of cystocele 
Iwlore or tluriug prt'pimncy. History of urinar>' retention. 
During lalnir: inteiiHo |tain ; veHctil U'ni«mu» unil Uysuriu. 
May l)e inbituken for hiv^ of waters ; (li!igm>?!icate by feeliug 
|>rv±}eutii)g part above and behind MaUdur tumor, and by re* 



FlO. 252. 




Cy^tufulL- otnitnirtlnK labor. 

dnction iu size f»f tumor by oatlieteri^m. Diagnosis from 
bydrocephalio head by snme meana, and by recoirnition of 
cnlarjred sutures, fimtatielles, etc, of cranium. 

Trrntmrnt — Cathelerij^m, which is difficult, and mntf l>e im- 
|x)flBible, requiring puncture or aspiration through vesiot>> 



OCCLUSIoy OF £XTERXAL OS VTERl 499 

viig^inat wpLum. Push ha<'k tir hold up the prolajisetl wall 
during puin.s lill the head sUp hy it, 

Ki-i_Tr)rKi,K — Pmn.ApsK OK Re(Tii-vaginal Wall — ia 
]»rodii('ed, much \\\ the winie nmnner, by diateiition of rectum 
hy i'l'cul fonkMilH, mid pusldii^ tlowu of projecting recto- 
va;rinal |x)uch by advuiiciii;^' fn'tus. 

Dintjuomii. — My putty-like 0(>n.«istt'nce of tunii»r, antl in^Um- 
tatiou of it-? coiUiMitji by digital pressure tlirough recto-vaginal 
wali» or exaniiiiatiou jicr anitvi. 

TreatvwuL — Heniuve fecal aeeuniulHtioii by emollient ene- 
nmta, or scoop out hard masses with ?iKM>ii-haii<lle or finger. 
Push back prolapsed wall ubite iicnd pur^Jetf by it* 

lMPAt-rKi> Fkci«, without reotocete^ inny be sutfieicnt to 
olwlruct deliver)'. 

TrenfmKnt Siuiie as alnjve described. Prophylaxis by laxa- 
tivea during pregnnncy. 

Vkhh'ai. Cai-cam's — Stonk in tiik Ri.addkh — when of 
coi»!fideralde size may, very rarely, olwtruct labor, and lead to 
cyHtm'^l(\ or vefini-vngiiial fistula from cnniprcspion of vgsik'O- 
vaginal wall between cnlculuii and Wx-XaX liead. 

Diogn<^si» (from ex(i8l<.«is, etc. )- — By mobility of calculus, 
felt ;)f/' wiffinnm, In'tweeu the jKiins, as a hard tumor l)fbiud 
and WMnetimes alH)ve the jmbe?, and by wmnding bladder. 

Ti'ifthnr'tiL — I Jt> the stone alxAo the jr-Ivic brim by digital 
piilpatiou per tKujiuam, If litis \n* impracticable, crush it, or 
extnict throtigh rapidly dilated urethra. If thes^e be too 
(eilinus, jHirform vagitml lithotomy through neck of bladder. 
Vesical calculus recoguizeil during pregnancy should be re- 
move<l U'fore lalxjr. 

OwLUBioN OF External Ob Uteri. — The li]M of the oa 
are either completely clo6ie»l from former adhe^•ive inflamma- 
tion, or an oK-terved i.>r unoK-ierved opening may exist of m 
Bumll a size a« to constitute^ liractical wcluMon ho far as de- 
livery is cijncertied. The adhesions may have followed trau- 
matism of the parts frotn instruments used in producing abor- 
tion, or cnuteriznlion, lacerations, ulcers, etc 

Symjitamn nml D'uitjnt}«i«, — A thence of the 06 on pnlputioa 



600 



DIFFlCt'LT LABOR. 



and even oii inspection by speculum. A circular dimple lu*^ 
be ret'ognized whero the oj»enin^ ought to be. The cervix 
ami iiiieriiul os arc widely •list<^nded, |KTh]ipa by tlie advaut*- 
io^ heuxl. their tL«ut« beini^ sit thin vtA to iiere&tilate care nnt 
to misUtku thetii tor tite I'a'tid ineiiil»raiies ; the rei'dguitiou 
of their ooutiuiiity with the VM^riiml wall would prevent tlie 
mistake. In uterine Intend ubii(|ullieH uiid exii^^^ruted aut^v 
or relro-version, an exi^linj^ oa uteri may be nlie<l out of reach 
of thti finger in ordinary vaginal exaniinatiun, the oe only 
being iliiM'overe<l by paAiingtlie whole hand through the vulva, 
and iboroughly exploring every part of the vaginal rooC 

Wheu welusiuu really exist** there is danger of ru|>ture of 
the uterus, as well as of "tediuus" lalxjr, if relief l>e not 
ail ordeal. 

TfCftivtetiL — Make an opening where the ne ought to he- 
Having found the cin'uhir dimple alM>ve stuU'd. it nniy, if the 
oliatrUL'iiDg septum l>c thin, 1»« |>eiietrate<l by {fre^ure of the 
finger or finger-nail during the piling. Tuder other circuin- 
etimees a ^niall erueial ineisiou nuwl be made, preferably with 
a guarded bistoury', over the ^tue »pot. or, when no dintplc 
can l»e di»covere<l. over the nioyl deiK-ndeut ]>i»int of the dis- 
tended rervix. Tents and chwtie bagT? may U* uH^eseary to 
complete dilatation if it fail to lake plu<^« Hponiniu'onsly. lu 
a few coAeA, where no triu;e t>f the o.^ c^>uhl be diauovered, 
Ctf^arenn section baa been itueceHsfully jierformed. 

Atresia of Tterink Cekvix (within the external ob) 
recjuin^ either vertical .shallow ineistons or gradual nitH^baui- 
cat dilatjLtiou by lamiuarin teuto and water-bag dilaton*. 

Cascer of the Ckrvix Uteri. — Wlieu ouly iuvolving 
the lower jX)rtiou of the eervieal canal, the diseaiied tiBf$ue« 
will often yield euougli Lo ndinil delivery. When extending 
hijrher up, the (^neeroiis growth, by its aize and want of 
ebiaticity. either prevents |>a»uige of child, or ruptures witli 
severe hemt)rrhage, 

ProffJUMiA. — -Of course, most grave. 

TretitmftiL — Incision of cervix, with applicntiou of fierchlu- 
ride of iron, or ioflofi^rm gauw, to stop bleeding. Perforation 
may l)e afterwarti ueeeiwary. if ein^unjAtiiuces denuiud im- 
meiljnie delivery. Another plan, certainly preferable so fiir 





FIBROID TVMOnS OF THE UTERUS. 



501 



as the rhild is concerned, and. in !iad canes, not adv^rw lo ibe 
molliL'r'f interest, is to i)orform (_'tf«ireu[i Bertion hh mmmi hs 
InUir l>e^iiiK. Miism^a ot'tlie rtincerous growth may *)melini<« 
Ik- Urokfii away with the hmid, making a sutHnent opening 
to n<lniiL vereiun, ur Ibrcejifi. 

C*Y8Tio, Fibrous, and CxyrERora Growths developed 
IN Vaoinal Walls may, very rarely, lead to sufficient oh- 
Btruction to re<juire operative a.'viplunce iK'fore <ielivery can 
tiike place. If small and removul)le, the growth shonid be 
renioviMl. U- not, and the tiimi>r i.s hard and unyieUiing, 
craiiicitomv or Ca»areaii section hecome last retiort*. 



Polypi of the Uterus — pediuulnteil fibrous turaora — 
hunirin^r in the ptirturienc canal, may 1>e of sufHcient size to 
oliHtruct lalwr. (See Fig. 25:-!. |>nge .~>02. ) 

DUujhOjtij'. — By their mobility — it' not impacted — inwnsi- 
liility. |)e<lit'idation, etc. Small ones might, witliout care, be 
mitftttkeii for swollen K'rotuni of breech presentation. 

Ti't^atmnft. — Ptwh the tumor up, out of the way, above 
8ii|»erior wtrail, nnd retain it there till bead take ]irecedem'e 
in deitcenl. When the |)e<licle is eii^^ily rcachcti, rennAe the 
irntwth by vcniitrar or .-M-issors. 8ome break otT during labor, 
and come away of tbenititlves. Some are sufficientiy com- 
prt^Hible as not to prevent delivery. 

FiBROin Tumors of thk Uterus — not pedioulnted — 
whether subscrouH, submuct»u8, or interstitial, may nr may not 
obstruct delivery, accordine: to their size and position. If 
high up, above the SH|>eriorstnut, they produce no olM)truction, 
but may render |>aiiif incHirieiit from a.symnietrirnl uterine 
(Nintractitnt. and p^^'^li?^[x)?^• to atitc- and ptiMi-puHni hnnor- 
rhtvje^ us well aH to abnormal ]ire^utation an<l position of the 
child. Situated below the Itrini, in the lower seirment of the 
wumli. lliey noccKSiiriiy ob.«iruet labor, and may in* large 
enough nearly to till the |:)elvic cavity. 

J)itnjhojti^ — Ky luptory of the tumor, its slow growth and at- 
tendant symptoms before pregaaney, and by its Hrmne^ want 
of Hucluation, etc. 

Trvifment. — In all cases extra precaution against occurrence 
of |Mist-partal hemorrliagc, Appli<'ali«ins of styptic iron «olu- 



602 



PJFFICrLT LABOR. 



lions ^'cntTully uect-ssiiry lo arrest it, Tumurs below the hrim, 
even in uppureiitly very unproinitiin^ cil-^-s, may be |>ut$betl 
up rt/wir it by |»ersi»teut pressure with llie Imml or <'|c»e.e<l firt, 
the pntieiit l^in^^ aiia-athfilize*!. The kuee-ellMtw pitsitiori mny 
iacilitjile succewi. Surgiciil iiiterfereuce, enucleation of the 

Fig. 3&3. 





Pfjlypu* ol>8truettng labor. 

tumor, or its removal with ^rraseur, when llie hn*e is not 
large, may he afiviwihle. The only other n.Miie<lic* in bnd 
cases are Cii^areAii seoiion ami craniotomy, in a Iej*er de^et? 
of obstrutitiou forceps or version may suffice. 

OvARiAS Tumors, whether »>lid or cystic, occupying tfae 




OVAKIAS TUMORS, 



503 



pelvic cavity, usually between vagioa and rectum, may ob- 

atruct delivery. (See Fig. 264.) 

The (/(v/jvv of ol«lru<'iiou de|K'n(ls U|tuu the s^ize, hanliieiw, 
and iMisitiou iA' tlie tumor, ami upou ita itmbility. Ajjart 
froui ol>8tructiou there is danger that the tumor may burst 



Fro. 2M. 




iJviirlnn tumor in pelvic rnvhy otrttnictliije lubor. 



during lalxir into the i)eritoneiim and probR-e fatal [Kritonilia 
or llie jMMliclc may jjiH, twistod and break of. Verif larjre 
ovarian tumors are less dnnirertJU.-* than rne<linni-*ized ones, 
becauiie tliey are usually discovered before lalmr, and, further, 
because they are too large tu get below the pelvic brim. 



504 



DTFFJCVLT LABOR, 



Diatjtiottiit. — Ry tlip piwitioM of the tumor; by it*« fliirhi 
mill ('oiifistencv. Fifnuid luinor of the ovary may, ht 
Ik* h> hrtH as to refiemhle l»fniy k'^****^^'' *'f *^'^ pelvia? ; erro 
rytrtif one* iiiny lie W) leuee a*^ to rwiuire puncture with trocar 
or tuipirntor l>efore their nature eau l>e ixwilively a^rcrrtainetL 

TrtahtteiiU — Altonipt to pii:*h tumor above the i>eivio brim 
out of the way. Pai^Utent pressure, under an»>ithesia, the 
woman being in a kuee-eheiit ]H»itioD, may uuexpfH-t^'jIly suo 
ceed. It may, however, fail, Itecause tumor Ls a4lher(*iJU or 
of large size, or held down liy the presenting part t>f the child. 
Then puncture cy»»t through vaginal w«ll with trocar aud 
eauula, and retain uiiiil Huid be evacuaieil, and \i' fluid be 
too thick t4) flow reu^lily, make digital preeeure upon Uie 
tumor per vayittatn. When no trocar is obtaitmble make a 
smnll ineitdon in the tumor, anil, after emptying it, stitch up 
the wound. ^^ho^ld puncture tail to reme*(y the diliiculty, 
from llie tumor l»eing solid, llie I'hild nui^^t be delivere*! by 
wlmtever 'iftttetrir ojwrtititm the ^jmce will allow, or, iij^teail of 
this tlie tumor ilBi'lf must l»e removed by a .turrjifJt/ operation 
— vaginal ovariotomy. Nbif^t «i^es are relieved by puncture 
of the n-8t. 

The diagnotsis of ovarian tumors having l»een marie during 
ffvetjnamy (if., beforf htf/or f/*fjineu it nhouUi l>e removed bv 
alxlotninal «>otion, a-s in other caseft. The 0|H.'ration does ti«l 
interrupt the preL'narn.y. if care lie taken to handle the utertu 
as little as |)OHsible. 

Hkrma or pKE<iNANT I'TKRf!*. — The varictiefi of hernia 
are the noii-gravi*l uteriL**, namctl in the onier of frequoucy, 
are: HmAi'/*VvA tKutmK Jr-nwral-t hi*fuinaf^ through t\ie Jofamrn 
ora/f, and through the great mero-KcitUie Jonnnnt, All fbrnts 
are rare; and for the uterus while ihxw dislomtinl to l>e4ix>iue 
pretjtHiitt, still more rare. Pregnancy has never Ix-en observer! 
in uterine hernia through the fonunen ovale or great tmrro- 
M'iatic foramen. Inffuiunf^ umbi/ica/y and JmtnnJ uterine 
heruiiuf have liecn observtsl with pregmuiey. The ittguinal 
aud fenutmi case* always end in nlwrtion or premature labor 
— the aac of an nmbUlrnl hernia may cxmtain a uterus far ad- 
Vrtnctsl in pregnane}'. 

Diagiiomn. — \\\ aliseiice of uterus from ita nomml flitiiatioa, 
by 8hH|>e and cuuHisttencr of tumor, and evidences of ita con- 



h 



PROLAPSE OF FCMSSnonT OR COILED FCMS. ,005 

tfliuing a frettiK In iDguinnl nnd femoral cn^ett the cuiiul of 
tlie vujriim in Jrnwn on ont^ Hidt townni tin? hernia. 

Treutmrut. — HephuTt wun»l) ami Hpply lru>s. If growth of 
prej^uaury alrwuly loo jrrejit for this, iutluit; alwrtion nr de- 
livery. Growth may he so large as to reijuire divwion of 
hernial ring lo iiermit delivery. If this fail, hysterotomy. 

Ventruf uterme hernia with pr^uauoy owurs more fre- 
quently ; is due to separation of recti museles, or of dilatation 
of larg'e eieutrix aller lajmrotoniy. Many of those arc iwt 
nai hernia — the wie bein^j contaiue^l within the fasciie — but 
ordinary "penduloun belly." If the woman, while on her 
back, atleinpt to raise the uj)per |part of her body, the preg- 
nant womb will protrude as a globular tumor in the linea 
alba. 

Treatment. — An abdominal Imndage. These rentral cat^es go 
to "term ;*' deliver)' not generally interioreil with. 



CHAPTKU XXXI. 

TROLAPSE OF FUSIH — SHORT OR COILED FUKtS. 

pROLAPSK OF FiTNifl. — A l<H»p of the umbilicnl eord han^ 
down aluojL^ide of. or below, the presenting part of llie ehild. 
hefuri' rupture of the membrani* it is called **}trt\-*ruiuf ton '^ 
of the futiie ; u/fcr rupture, when ibe loop fnlU down into the 
vagina^ ^* prnfapur" (See Fig. 255, |Mige 5(>*i. } 

Cansf'i^. — Conditions in which the prei^enting part of the 
child does not completely fill, or block up, the ring of ihe os 
uteri and pelvic brim, vix.. pelvic contraction or deformity ; 
trHUBverse. tootling, knee, Itreech, and face presentations. 

It may o<"i'ur iu ordinary* head presentation?, as well na 
ouiler the circnniintaiice;? just stated, from unn^ual length of 
the Curd ; iiiaertiou of placenta near the os uteri ; exct*** of 
li(jiiur aninii, and gush of amniotic Moid when niembraues 
rupture at the height of a lal>or pain ; nnd in multiple prcg- 
nancy. Head prei«entation complicated with that of a Jiand 
or foot, or with l>oth, e»]KH*ially favors |)rola[)se of cord. Fnjm 



506 PROLAPSE OF FUyiS—SnORT OR COILED rVSlS, 

the fiir ^reattr rrfatiir nunil>er of lien«l presetifations there artl 
nmro onric^ of |in»la|K«Ml t'liniH nssociiitwl with tfitin thnii witli 
prej^eutntioui* ot'otliiT purta, B\it in a jpveii eq\t/il nu[iil«er uf 
each [)resonta(iu(i, prolapfte of the cord will be found Iea4 

Fio. 3S6. 




l*niUpM of itae font by the ride of the hMd. 

frw|iipntly with head rases, for the reasou before stated. 

SciUirtoni'M tigurwj are : 

Funis pre<ieDts unce iu 304 head cases. 
** " •• 32 face rafies. 

" " " 21 |»e]vic (*a»e«. 

*' ** " 12 trauBverse cnsee. 



Thu? 




PItOLAPSE OF FUNIS. 



507 



Prognosis, — Not unfavoraMe tn the mother, except in so 
fur ua iiiny result from rinutiotitil (lislurhaiK'e nnd siihsequeut 
brenst troulilet- from chihl In-iri^ iMiru ilwid. 

As rejnirils the rhiUI, il L-* a iin>st j^-rious eompliralion. 
About r»0 [Kjr cviiL die, owiiijr to I'onipn^srtioii of futiifi during 
delivery. The dangers are letw in prt^jiorlion to the ^^reater 
length of time that the memlirunes are rmruplnred, and when 
the presentiition and other comlitions are favorable to rapid 
delivery nftrr their rupture. Henre breech prpjientalions, 
which admit of P|>eedy extraction, are oouiparatively favor- 
able. The breech, moreover, is softer and !»maller than the 
bead ; hence there is lews iear of fatal pressure on funis. 
Transverse caj»ei* do not ne(.^c«iariiy involve pressure of the 
cord, and are hss dan^erouH than head prcs^nilaiions in thin 
respfcL A lar^e i^ielvis is favorable. C/d'avorable conditions 
are ftrimijxinttj (owing to length of labor from reftistanoe of 
Boft. parts), contracied pelvU^ low placental itijseriinu, and enrly 
rupture of membranes. 

hlftgaottiii njay be attended with mmc diffieulty before mem- 
bianeH rupture, the tln^rer liavinp to feel the «)rd through 
them, or ihriMigli the thimunl uterine wall. It feels a soft, 
wmipiN'Sr-iliie. :uid ntovable Ujdy. in whicli pulwitions, nyn- 
chrniiou?' with the fieial heart, may be recognizetl. Frei*sure 
of cord during a pain may temporarily interrujit pulsations. 
Pulsations in vaginal or uterine wall are synchronous with 
inolhrrA pulse, ronfounding lingers or toes of cliild with funis 
is avoidefl by remembering their harder consistency, number, 
and Ivy absence of recognizable pulsations iu them. In cases 
of uli-rine rupture a prolapwMi itnl of emull iiilwtine has been 
mistaken tor funis. The attachtMl mesentry, and want of 
pulsation in the intestine, are sufficiently diagnostic with 
onlinury care. When the membranes have ruptured, or the 
presenting cord has ))rola|^)sed into the vagina, there con 
scarcely l)e any nnstnke. I'ndiiliail pulsation, of a)ur8e. 
shows child to be alive^ but the |>ulBaiion may ceane some time 
before the infant dies; hence auseultiite for heart-sounds 
iK'forc ih'uth is as*umeil to have oi-curred. 

Ttrnimrnt — I*r(*serve the n)end)ranes frcan rupture as long 
as possible. The cord is safer from pressure, when l)ng of 
waters is ii)ta<*t, than it can be made by any operative treat- 
ment after membranes rupture. One exception noted l>elow. 




508 PROLAPSE OF FVNIS^SlfOnT OR COTLED FUNIS. 

Poshiral TretdinriiL — Before memhranes rupture pla<*e the 
voiiiiiii upon hi^r side — u|)uii the KidcupiKisitc lliut upiin whk-h 
the e^nl lit-i* — iiud elevate the pelvtf ujM»n pilldws, while ibe 
head and chest rest low. The roril may tliui* *rravitat6 toward 
fundus uteri durinn early part of labor. The kiiee-cheet or 
knee-elbow fK»sitioii are more cHeclive^ but difficult to main* 
tain for aoy cunsiderable time. C^'^* '^(i*) They Bbould be 

Fig. aw. 





Pofltuml trentment of prulapee of thy ronl- 

rcflorted to at inter%'nU during early ftnjre, the woman after- 
ward resuming her lateral jMiHtiou as aliove stated. I^ter 
on, when the os in sutficiently dilated for the head to pam, the 
woman may be plaiv^K teMi|K>ranly, in a decided kuee-elbow 
posture, when, if the cord nlip baek. the membranes arc to be 
ruptureiL and manual pressure applie<] externally to produce 
en^fajrenient of Uie head, which laj<t fills* the o|;»eninp, and pre- 
vents reprola|)«;, the wtmian suhsequeuUy ret^uminir and main* 
taininc: her latero-prone poinlion. 

Should iMJflture alone not puffiee to cause the ctird to slip 
hack, let the membranes remain inlaeL 

WhiMi, finally, they rupture, artificial reposition of the cord 
mupt 1k^ attempted. There are several methcMln of o|X'nitiiip, 
all of them beinp: more likely to 8u<*i*eHl when the woman ia 
placed in the knee-ebe?t {xMitiun. The hand may be carefully 




PROLAPSE OF FUyiS, 



509 



piwsed into the woinh wilh llic l«»op of cord protected in its 
palm, until the lorip i.s (.>nrrietl aliove the e<|uat(ir of the heud 
to the hark of the rhild's nwk, the fundus uteri hein^ mean- 
while bUf)(K>rted with the other huiid. and tlie hejtd gently 
pushe<l Uiiide wh&u the inner hand pu^^ies .ilonp^ide uf it 
Whpu thin prueeediu^' is imidvisahle. or iinj>()tt>ihle, Crom the 
head having des<:eniti'd tm> low, two or lliree finicen* may he 
usi'd to [lUHh up the loitp, and hold it aliove the ctpintor of 
the head until the latter i:* ii>roed down hy a aucceediug paiu, 
when the fiti;^ers are withdrawn. Repeat during several suc- 
(vsr^ive jiains, if nererfwiry. 

In lieu of the hand or Hugers, various rrjMuiior* Imve l»een 
devit^ed. A ta)K; and sty letted male ehifdic cjitlieter answer 
as well as any of them. A piece of tape three or fimr feel 
lon^ is (inuhled, cihI to end, and parvod into the catheter so 
that the tn|^ loop van l>e drawn out an inch or two throuju'h 
the eye of the instrument. The stylet is also p»».-*i(Nl in, and 
it-^ extremity made to project from the eye of the nitheter. 
The hmp of tape is next jwissed round the \oo\t of cord, 
antl h(Hiked over the projecting end of the stylet, which last 
is pushed hack into the eye, and shoved up «iui1e to the chisefl 
end of the catheter. The two ei»ils of the tii|H' may now l*e 
gently drawn U[k)u, until the loop loosely hoUls the cord in 
oimtart wilh the instrument. The proI«|*s(><i funis is then 
pushL'd up into the uterus hy tlie catheter until it is quite 
iii)nve the presoMjtinjj jmrt of llie child, when, hy withdrawititf 
the stylet, the cord is release*!. The catheter and ia|M> may 
he left in till laI>or w over. A nhnitlrr mrthwl : The loop of 
tfl|>e, instead of hein^ passed all throuj^h the cjilhetor. is simply 
dok'^hI into the rye of it and over the end of the stylet, which 
last is pushpJ ti[» to secure it ; the free ends of the tape may now 
lie loosely tied round the Untp of cord and the catheter intro- 
duced \\» Itefore, nn<l stylet removed. (See Fi;;. '257, pa;.^e 510.) 

Or, niraiii, a catheter nmy he uswl with fwo rifrn, ojtpoHite 
each other; the loop of tain*, or strinir, is pa.s'tMl transversidy 
thronirh hfttk eyes, then rouiul the navel-string, then over the 
end of the caiheler (see Piir. 2'>H, iiatre 510 i, when the ends of 
the taix", passing alonjr the shat^ of the cntlieter. are drawn li>fht 
euou^'h to h(dd funis, etc. Stylet to he used for inlruduiiiig it, 
and withdrawn alXerward, leaving eutheter. etc, in utero. A 
flat pie'f) of whalehono, having nn eye near one end, Uiroiigh 



510 PROLAPSE OF FVNIS—SNORT OR CVILED FUy/S, 



which a loop of ta|»e may he threadeil, hua nls(» hct'ii oniployod 
ill 11 Kmiewlmt nimilMr iituuuiT, ami, ulter re|)U8ition. iHl iu 
till the child is Iwru. Other methods of usiiij^ (hu culheler, 
tajx*, niul ntylet hto phowii in Fip>. 2"ii>, 260, and 2t>l. |>aj:e 
51 1, which expluiti thetiiM'ivii*. Ivetenlion ut'a icphu*eil funis 
hiis bwri secured by atlachiii;^ to tlie cord a coUn^wncil ehti^tic 
bag or |»eftiary, baviug a tube by which it may b« iiitlated^ 



FtQ. 357. 



Kio. '£i». 





Kpr>*^ttlon of conl. (After 

WiTKOWfiKl.) 



£rauu'0 n>t»niitilitn of voni. 

(W'lTKoWSKI.J 



after introduction into the uteriDc cavity — eo-called "balluon- 
ing " the conl. 

When rcixti«ition fiiils. ui» it i^ often wont to «lr), the next 
element of treatment, generally 8|>eiikin};, it* npet'dy delivenj ; 
or, when circunt>'tJitKvA remler tl»i:< iinpriu'ticable, it niay l»e 
attempteil l<» place the cord whert* it will rt*ceive u miitiwitm 
nmmint of prfMtirc. Thuf, when the <w<iput in jtUicp*! at one 
of the acctabula, the hx>pof tlie cord should be put ne«r the 



PROLAPSE OP FUNIS. 



611 



sarra-iHiH' ;:*yn<'lioniIro»is of llie Minie sitle. In liretM'li prt'sen- 
liitions |)ut it near the sacro-iliao synclKHidrosis which a»rre- 
sijoufbi to the aotero-potiterior diameter of the hreevb. 



Fin. 3M) 



Pia. 261. 




Other methods of roposltion of cord. 

8|>oe<]y "Iplivery may In? sttMired hy forceps when the oe ifl 
dilated iiitd tlie head Kiifticientty l(»w. 

When fi>r(.'e|K* are iM)t Hviiiluhle, the next alternnfive ih 
vt-mon by the j)t% preferably by extertial or by eonibiue*] ex- 
ternal and iuteruul munipulatiuu^ aud 8ubt«e(]iieut rapid ex- 



512 PROLAPSE OP FUMS—SIfORT OR COILED FUNIS. 



tracduQ. The tlaujrers of veraion, especially when the ooudi- 
dons tor iU itm^y aiwl aiiUi iK'n'orniaiife arc not prcsonl, hLoiiUI, 
in tho iutvrejtte of the uiotlicr, Iw earuwtly rDii^iilertwi before 
the 0{>eraiioii is a^rei'il upon. It ^hotihi hi' al.so ascertained 
that pr<.«ure uikju the oonl has uot iilroady so tar hijunxi the 
chilli as to render lis chunrt':^ of fliirvival, alter vcrHiun, insuffi- 
cient to justify any risk to the mother that may be iucurreJ 
by the operadou. 

The oiH*ratii)u of verisiou, together with re|K)sition of Uie 
oonl, may Iw? lat-ililateil by putting the woman in the Tren- 
delenburi? |H»stur<'. 

In lace pri^jentations, when o]>erative iiiterfercuce is <le*.'ide<l 
U|)<Mi to siive the rhiM's life, au mrftf resort Ir) veryion is the 
hent, that is, when other melhoils of relieving the curd from 
pre*<ure have failed. 

In hreeeh niscfl (he extremities should \w brouj^ht thiwn, 
and the chiUI rapi*Ily extrnrte<i by the methods already i<tate<1. 
(S<!e '* Hree<*L Presentations," pages 2i)4-2yi>.) Footling* tbo 
same. 

In case's of prolapseil funis Hi*3oeiiiled with conli-acteil i)elvi» 
or with trnnsverse |>refieututions, the treatment retpanHl for 
thesi' <*<mipliealions, in the interei*t of the mother, must take 
precedenre of that solely relatinir (o tlie iuterests of the ehil<l. 

When pn>l«p*ed funis 'i» aa!*o<iate*l, in hejul presentatiuns^ 
with coincident prola|we of a liand (s*^* Fij^. 2t>2, |Mige 513), 
the prola|)se<l extremity should l>e replaced with the funis, 
and the head made to descend and BU up the space so as to 
prevent reprola|jist'. Care must be Uiken not to displace the 
heaid ami thus pr<hUic** transverse presentation ; it is best pre- 
vented by ubdfuiiinal pressure during the procee<ling. 

When a fiH*t pn'S4'nls with the cord and head, or when foot, 
hand, hfiid, and cord uU present at once, it will usually he 
iHtft to draw down tlie f*H)t, wliile (he head, cord, etc., are 
pushed up, thus [>nnlucinj^ veixion by the feel. Such pre:*en- 
tutiuuH are t€chni<*«lly known as " complicated" or **^ complex" 
ories ; and are also so called when the cord <ioe9 not prolapse. 
(Seo " FtKitling Cases," page 304.) When the |>elvis is large, 
prolapse of a haml alongside of the head may stitt admit uf 
s|)ontanoous ileliror)', or foitvps may l>e applied if the ex- 
tremities cannot be rt'placed and progrt^ss is ninth ini[H*dt*<l 
liy the complication. When the child is dead, prola]ise of 




SUOJiT ASD COILED FILMS. 



513 



the roH requires no interference. In nil au«es where ho|H.' of 
WW' rviuixusA, prefttire l»eforehaud far resuscitation hy proviJiug 
hut ami viAd water, hnuidy, electricily, etc 



P1U.2GX 




Hand prolapec<l by tUW v( heftd. Tbe prol«i«t.M) cord it nol represented. 



Short and Coilkp Ft^Nia. — AHuai 8hortn«»of the rord 
(easee hnve been Heeu :i« short iw two inehes). or nriifirial 
shortening, hy its bt'ing coile»l nnmnil the neek. IkhJv. or other 
parts of the ehild, very rarely oHers roimidrraUr nieehniiieal 
ot»struftinn to delivery, nnd more fre<|uently a tiight prohtngn- 
lion of the i^tMtnd singe *jf hilnir rcflultj*. Very long cvirda, of 
even six or eight feet iu length (such have beea obeerved), msy 

33 



614 PROLAPSE OF FtlNTSSlfORT OS COILED FUyiS. 



be prartioally »!)ort, from wiilirip. From stretobing of a short 
or coiled ntrtl duriiifr bibor tbere may result, tboiigh very 
rnrt'ly. iiiVfi>ioii ut' the uUTiia, |irfnmturi* wponilioii of (be 
jilat'eiitn ami beinorrba^e, rupture of ibe funis or interference 
wilb itii eircubitioiK und deatb of tlit* intiiul. Tbe blroiijrw4 
conis rupture under a tension of li) j.n>und8 ; tbe weaker on(« 
l»eur only about H pouuds; tbe average Btrength about 8 
pound*. 

Stfinptt/niJ^. — Before extrusion of tbe rbildV bead, tbe dia^- 
noeis of a shortened funii" ij* not always easy. The foUowin^ 
syuiptonis timy l>e preaeDt : a |,ieculiar puin, or poreuess, felt 
during uterine rontraction, usually bigb up at tbe t^upI)05ed 
plaeentnl ?iite, which is deserilM-d by multijuvne as lieinjr differ- 
ent fn^ni the sutferin<r proiluoed by onlinnry Inlxir pnina. 
I,ater on there is [jarlial arrest of labor paius, especially of 
bearinjr-^lown eftbrts ; and retnniation in dei*eenl of prej^enting 
{Niri, with elastic retraction of it^ l>etween tbe |)aiiift, to a 
^'■reater degree than can be liocounletl for by resistance of 
maternal soft parte. HKmmI may be disfbarjrtMl lu'fore birth, 
owing to {rnrlial :*ej>iiration of placenta, and when there are 
no ooexi8iin>f bwenuionH of cervix, etc., to explain it. De- 
prcj^ion of placental site, during |tanti^ felt through ab- 
dominal uall.(?) An unusually pers^iatent desire on tbe part 
of the wouiau to Bit up. not occasioneil by fulness of bladder 
or rectum. A finger pa&ied high up into tbe vagina or 
rectum may feel mi exi*rting coil. 

Troitwrnt. — None is required in the large majority of Cftfieei. 
other than relense of a coil round tbe neck at\er the head is 
lM)rn. Tbe coil u* l<H>eened by drawing it down lo fitrni a 
loo|). which is then passed over the oc4'iput, Hannless or at 
loa^t rcmediiibb* coils of this sort occur once in about every 
five lalwirs. When the cord is ti>o *hort to admit of release in 
this way, cut it, after two ligntiont*. and deliver at once* to 
prevent tbe child bleeiling and sutlbcHtiug 

When lalhir bt unduly retarded fnmi a short cord before the 
head iti born, let the woman iiKstmie a fitting or kneeLing 
posture upon the be^l. and lean forward during the pains. 
The whole wood) i»t thus pufhc«l down and tenaon nf the 
cord relaxed, while ih*- head, if its rotation have not previ- 
ously taken place, will nitnte, and «» Ite preventwl fnmi re- 
tracting between tbe ]iain8, tbuis atfordiug the succeeding 



ANJRSTHnTICS. 



515 



uterine coulractioua a lietler cliatK'e of completing <lelivery. 
Siii>it](l foropjiH \w. Uif«<l ill Kucli coiiOH, owing to 8Viu|iU)uiti of 
teiliuti^ lubor. care \\\\i»i l>e taken not tu invert the womb. A 
ct>ril that is very short amy require division, in utero, l»efore 
the hwul can be safely exirucaetl. Such Oii*e» are extremely 
rare. Kuoh in the fioni ilo not inijKMic delivery, but may 
interrtipt the circulation, and thus destroy Lite of tietus, when 
lij;htly drawn. 



CHAPTER XXXII. 



ANESTHETICS 



CHLOROFOR>I, HTHER, 



CHLORAL^ ERGOT, 



AN.i^:?rrHKTUT^ are U8e<l in obet^trios to lessen suffering pro- 
dueetl by lid>or piiins; to le*ien the [miii attending o^>^^tet^ic 
o|X'raliona; to relax the uterus when its rigid coiitniction 
interferes with veraion ; to promote dilatation of the 08 uteri ; 
to re»luee exc«wive nervous excitement which may iiileriere 
with progre«* of early stage of ialntr ; to relieve eclamptic 
coiivul>iioii» and mania; to relax the nlMloniinal wall and 
leaeen pain, wldlo the uterua m iH-ing puttheil down; in cases 
uf alK)rti<ni when the finger is l>eing intrfMlnewl to remove 
retained s^H-nodiiierJ ; in craniotomy to forestall unpleasant 
retrolliM'tions ; in ciwes of uterine inversion to relax the 
consitrietiiig <'ervix and so facilitate replacement; in l>i|)olar 
version in lessen |Mdn of introducing the hand into vagina ; 
in precipitate labor to suspend action of voluntary muscles 
nnil reami delivery; to dissijmte *' phantom tumors" while 
nmkifig a ditferenlial diagnotfis of prtigunncy ; to relax the 
OS and cervix uteri while intrtnlucing finger to <lingiM»*tieute 
betweeu uterine and extni-uterine pregnaney ; in all cntiing 
o(>erations upon the abdomen ; and sometimes in sewiii<: up a 
lui'crated ]ierineum when many sutures nre re<piire<l. In this 
las: iiL-tance, and in all nises wben an ana^thetic is used a/^t 
ttrtii'frtj, the greatest carc^ is no<*essjiry, for the rens>»im, 1st, 
that the patient has usuiilly lost, mtma blood- [HTha|is a g<MMl 
deal ; and 2d, the reiluclion of abdominal preiisure atVer d<y 



516 



ANJCSTIIETIGS. 



livery allows blood to flow trom the braiu toward the abtliv 
nien, hont^ea liability to cerebral Hiitemia and syuoope. Amee- 
thetiift lifter ilelivery sliould \w nvoided if fxj^ble. 

The practice of giving uuusthetira in ati coxes o^ labor, to 
lessen |»nin, has \vi^\\ warmly advocated iu certain quartera, 
but \» not, un the whole, advlwihle. 

Ck)mplete uiia^sthesia front chloroform, or ether, iindoiibi- 
etily lessens the force of uterine coutraeiion^ and thus retarda 
lultor, n>4 well as predi8|X]8inf; to {MkHt-partal heniorrhiige. 
Hydrate of ehloral, on the contrary, may l>e given in suffi- 
eient quantity to procure relief from sutfering without materi- 
ally interiif'riug with uterine eoiUraetiftn. 

The ehoiie l»etween ether an<l chlorofonn — the two aiiHe»- 
thetity geneniUy iwetl — is un:4ettled ; some prefer one, some 
the other. Ether i>t unqui«tionably i^fer ; and while the ad- 
vocates of chloroform claim tbat but very few deatlm are on 
record from itfi use when administered with uuremiuing care 
and by the hands of an e<luoated and exjxrienceil phyaeian, 
yet these i.t>odJtiMn8 c«nnot idwuys be wnHlnnlly nflsure<i. All 
men arc human ; the unremitting care will 6(fmetim<« remit ; 
oversights and diverte<l attentiun hap|)en to all, and in ob- 
stetric practice, with its inevitnble fatigue, kxw of f*lc*>p, and 
anxiety, are more likely to hap|)en than in other fields of nro- 
feanional work. Flence, as a matter of safety, 1 prefer etner. 
Iu (wte« of acute ana'inia following profiute hemorrhage, all 
agree tbat chlorf»forni is more dangerous than ether. Ether 
(Bulpburic etiier) nuiy Ik* safely given during the swond stage 
of ftrdinary lalM>r at the Iteginniiig of each pain, ami during 
its continuance, and ^huuld be so given, to let«en i^ul^'crinp 
when the Jigony i» nevere and the [wihent jmrlicularly sensi- 
tive ; but com|ilete ana-stbcsia arnl ini^cnsibility are not advis- 
able, from fear of |x«t-p»rtal hemorrhage, agaiiiBt the occur- 
rence of winch a double vigilance u* always ne<;eflHar>' when 
anieHtheticH have been u^ed. Ether \& not m liable to retard 
lalx^r from leteening the force of uterine contraction aa chloro- 
form, but it is not entirely free from this liability. It is ol>- 
J€K.'tionable during the early stage of IalK»r, and is distinctly 
coii/rrt-indicnieil when (here ifl kiilney diseaae. Ether is in- 
ttammable. nn<l hetK'e care ih required in using it at night. 

Chlorofobm, when giveu to leosen the agony of labor 





CHLORAL. 



517 



pains, HH it often ia in £un>|)0, thoujc:h much \v¥» frequently 
in the United Stntt^s. ii> iiMially ailniuiiiitere*! wlifii laUor \n 

^tretty Wfll atlvunciHl — w iit-ii (lie on uteri Ik wt^H (iilalctl, the 
leiul (Itt^cemliniLj, aurl idc pains are propulsive. A few f!rop« 
are |ilu(tMl iiiKtu a h:tij«lkiTcliiei'. iuu\ held nenr. not close lo 
the nicnjth, at the hfjiinniti^^ <»!' a |«iin. the inhalation l)einjr 
ccMiliiiue*! till tlif pain inusst-i^ ilH acnu*. when it is at onei' 
stoppt^l. Pure nir .shtnihl l)e breathed durinp the intervals. 
i'om/Jrie iuseiiiJiliility is n(»l di^irtHl ; the woman should re- 
niftiii Mufficii'ntly (xjnwiou» to eonver«e. Durinp li»e eurhf 
stape 4tt" lulM>r<'hloroforni should «^rtainly not lie piven merely 
to lesi^en [uiin. A mixture of uiie-third Hl)tiolule alcohol with 
two-thinU chloror<tmi i^ le«t> ohjwltonnble than chltirofurni 
alone. All the iwen to wliii-h rldnr*>forni nuiy 1k' applii'd in 
oliftelrifv may Ik' att;iirK"il- Ity clhcr, with the ex(vptit)ii that 
ehloroibrui in In-tter ihiiii ether when there is reual coiiiplic4i- 
tion. 

While it is generally admitted that ehloroforni is danp<»r»>us 
in (raw's of fatty heart ami in i«rdiae valvular iesiuna, it has 
neverthelew been given in lh<»f<e owes* witlnfut any aj)|iarent 
Imd eHW^ta. 

Durinp olwtefricnl operation? re<|uirinp ana*! bet i«?, an:ei*- 
tht-.si:i Mboubl \^ coinpb'ie ; if it Ite only [larlial, the patient 
iu liable lo tot«< almut without any control. 

In delivering with for«-eps, under aniisthej»ia. extra rare 18 
ii«ce(«or)* to uvuid pinehinp the soil tit^ui* of ulerut* and 
vagina in the grmip of the blades. Huce the jmtient, being 
inBeiihihle, cannot indicate, by her complainta, the occurrence 
of Buch u niit'bnp. 

Stronp coninic(i<>n8 of the uteruB, rendering irrmtm ex- 
tremely dirticull and dangerout* — or. perhapt*. im|Kit»ible — are 
at once relaxed by conifilete anavthejiia. The child having 
been turned, it flhonld not be extrncteil until the womb hap. 
at leJiKt in jmrt, rt«unied its eontrartile efforts, so as to lesien 
the danger of hemorrhage. 

When chloroform is given for puerj>enil eclam]«ia it should 
he adminigtereti juMt liefore the beginning of each retuming 
paroxysm in time to prevent the seizure. 

Chix>ral (hydrate of chloral) will probnhly. in great mea*- 
ure, take the place of chloroform and ether in obe^tetric 



518 




ilA'-iESTi/isTyca 



pra('ti(«, except when spvere o|)enitioii8 are required. Under 
iU iiiriuenc« the woman may sleep diirinjr labt^r without any 
^reiM mifferiii«r, l»ein^ (»nly aroustMl hy tW' rceurrtnire of pain&, 
the aguny of whieh is not then at^ule. It is efpeeially valu- 
ahle. n» iilrea^ty indirated, when the tin uteri is thin, n^il, 
and diHirult io dilute, in fiiet. durin;^ the early t^ta^ of laltur. 
when ether and ehloroform are iuadnii«sihle. Cldoral does 
not dimiiiifili uterine <*on1 faction. It. iiidee<I, le»«etw the Jr^ 
fjitencyofthe pains*, hut at the earae tin)e renders them stronger 
and vifire t-fficieni, cahiw nervous exeitenient, and promotes 
dilat4itiiin of the os. Fitleeu jrrains may l)e jjiveu in a little 
water or syrup of orange-peel, every twenty minulee, until 
two, thre«. or (pottfihly) four dtwies are iJiken. awrordiog" to the 
degree of sonutolenoe produced. More than a drachm during 
the whole lahor i» seldom require<l. Serious and even fatal 
symptoms have re«ulter| from U¥> large do«#. 

It i)ii distinctly rojWrfl-in<lirated in oi^anic cardiac lefdona 
and it^ safety is very questiouahle even in Junrliwiai diseoae 
of tlie heart. 

In puerperal et-lampeia chloral ia a most valunhle remedy, 
both during and after lahor. Large d<»ses of twenty or thirty 
grain.s may he taken ; or tivic** I his quantity may l>e given at m»re, 
by enema, and repeatetl in a few hours if the spasms reeur. 

As a sleep-proiluoer iu puerj^eral mania chloral is l>etter than 
opiunif hyoscyamus* or auy other narcotic. It may be com- 
bined, to advantage, with bromide of potassium (xv-xxx 
grains of each). 



BRoMiitE OF Etiiyl has been employed experimentally 
B8 an aiuuitlietie iu midwifery. Its utility has not yet lieeii 
sufficiently ih-rmmstrateil to warrant it5 recommendation. It 
requires the «ime prec4iutioii8 as chloroform in ili atlminis- 
tratioD, and shares the dangers of this latter drug. 

Ehoot (Secale Corkttum, Ergot of Rve, Spurred 
Rvk), though by no means allie<:l, in its action, with anas- 
Ibetica, may Ije here considered as one of the ohstetrieiau's 
special medicaments. Its etfeot on the uterus is exactly oppo. 
site to that of ether and chlorof4)rm. with which, indet^l, it is 
8ometiine$i administered as a sort of antidote to their relaxing 
etfect upon the utenue muscles. 



QTrmiNK 



519 



When given in ordinary full ijoses* (xx-xxx grains of the 
powder, or xx-xxx tninims of tht^ HiiiJ exlrart, or ^j of the 
tiucture, or wiue) er^ot [inwlucvs, in ihe foun^v ol' ten or iiU*t*n 
minutes, strong contrattioiis of the nfonis, whith» wlien the 
drug is repeated bo a« to ol>tuin it^i full efl'erU be(H)nie per- 
aiatent and cotttintuytm as well aa jtowtrj'uf. This Uniic aad 
unremitting pernM^'u^'e of the c-ontractions cotiatilut^'B one of 
the olilef drawbacks and dangers of ergot If the child l»e 
still unl>orn. coutinuous pressure U|Htu the eord, olelniction 
to the uten>|>lacvnlail eireulation, and conne^iuent injurv or 
death of the foetus may reault, unlt^'* sj^'edy deliver)' take 
ploi'e. Injury to the uterine wall from eominuouK pressure, 
or actual rupture of it may result, when there exists any 
meehaniPHl resistance to delivcrv. Henoc the following 
contra-indications to the us© of ergot may be positively af- 
firmed : pelvie deformity ; malprojxtrtion lietween the siv* of 
the L'liild and pelvis; transver^^ and other malpresentutions 
or [M>aitious of the fa*tus ; undilaled os uteri ; resisting, rigid 
|)eriueum. When powerful contraction? are jirodured by 
ergot, as may hap|)en from its injudii'iuus admini^-tralitm by 
nurses and (>thi-i><. and the labor is uof rapidly atrnpleted, 
furcefw shouhl be ap[)lie^i to relieve the child from danger — a 
proee<iure all the more imperatively ueefle*l if auscultation 
reveal irregularity or feebleness of the ftetal heart. On the 
whole, it is a siife rule to abstain from giving ergot at all 
before the child is born, except in retention of the nfter- 
ooming head in f)reech presentation:', as already explained. 
Its a<hninistmtion in certain cases of placenta prjevia is gen- 
erally reconmiended, ns well ns in aceiilental hemorrhage from 
sejmration of a normally placed phu*enta ; but, if the child is 
to l>e savefl, delivery must he expedite*! by every |M»S8ible or 
practicable means. Ergot was formerly used to indui'e prf- 
mature htior, but has now been abandoned for l>etter and lesfl 
dangerous methods. 

The chief use of ergot in midwifery is to secure |>erBi8lent 
uterine contraction at\er labor. It thus prevents hemorrhage 
and lessens tendency to atier-pains. 

QriNiNK (QiriNiA Stn.pHATK), though not yet generally 
use<l in labor cjises to reiuforoe feeble uterine contraction, has 
proved of suflicieut eHieaey in this resj>eet to warrant the hope 



620 PVKHPiiHAl ECLAMPSIA DVRIXa LABOR, 

timt it nmv form a aiii'e suhsLitute for ergot during ibe first 
atiii Het'oiid sirtjj^os of lal>or. J)<)8c, x-xv grains every three 
hours. Ill* elfiiarv iti relieviug aAer-jiains ha** l>een |ireviou8ly 
iiiviitioiieil. 

Keeetilly. w*iumun white stujar n\ one-ouDce doees. given in 
tialC a pint of water, every two hours. hn.s lieen highly reconi- 
meuded to >'lreii^theu uteriue contnu-tiuue during lalwr iu 
plaee of ergot Its value has uot ret [)eeii definitely proven. 



CHAPTER XXXIII 



PUERPERAL EtXAMPSIA DrRPTO LABOB. 



Puerperal eclampsia, apHoeiated with premature de- 
livery, due to urieniiu, from ulliuniiiuirin and renal ooiijrestion 
or iitriaiiiniatioi) during |)re|;iuii)ev, have heeii already ilt^- 
cu£tied in m far a> their etiology, rtvni|»tom», and prophiffot^tr 
treatment nre i-oiwerned.' Their obntetriv treatment thas not 
differ materially from that of ecIani|wia<K'Curring during lalnir 
at term, here to lie c<*nsidere<l. 

Puerjienil ('oiivuli*iotie diirinfr labor, besides arlnng from 
uneniia, may U* due to other forms of lilood-|»oidouiug, viz.. 
ehola-mia (retention of hih*) > im|ierfeet elinnnation of t^r- 
l>onie aeid hy the lunp* ; medicinal |K»i8on8, at* leatl, nureotirs, 
etc. ; sejitie jioiftins, ris tlKM»e of typhus and other fevers. The 
op[K)Hite (i}iiditi(»ns of conpfction and aiiieniia of the hniiu 
may prtMliuv erlam|:Hin ; as may aljso peneral ananda. plethora, 
hydra-mia. and leukit'inin. CVMivtilpiorf* often ]>recede death 
from hemorrhage dunn*? lahor. They may ariwf from violent 
emotional dislurbnnee. or fnun ret!ex irritation due to indi- 
gestible (imkI. feeal aecumulalior .s a dii«ttMide<l bladder, etc. 
The well-kn<»ttn in<'n'ase<i es<"itability (WM-nlled "convnlsi- 
bility")of the iiervoi;** MMem in pri'^imnt an<l parturient 
women predinptis^es to ecbimp^iu from slight (*au.*»es. 

Syjnptumji ami Cliuirnl Hintorv. — PreviouH tMrurrence of de- 
cided renal iiyniplt>mi*, j^ejieral ilropsy, ete,, during pregnaney, 
especially signs of impending unrnda. 

• Sec Chapter Vlll. p. 142. 





TREATMENT OF C0fiVULS!0S8 DURING LABOR. 521 

Prec'eiliii;; ihe actual iKxrurreiu'e of a t(|>asui there are irri- 
lulMlitv i>t" teiM|K.'r, slight nr K'vere hejuhielie. <iixziu(.*B, mi>ota 
IhI'uiv the eyes, iiiipairnieiit <?r In-is of t*i;rht, ftintitus aurium, 
hulliiriiuili'HLs, (hafuesw. iiitellectuul iliHturlMHice, uuiitfuul de^ 
fiire to »lee[j, with (>erliu|» stertorous brcAtbing, vomitiDg, etc 
Some or all of rh*5*e rimy Iw preaiMit. 

The uctuiii cuiivulaioii may re«emhle epUepsy or hysteria, 
Text-U')oks pive thtre varieties : epileptir, hystericHl. and 
aiHiplcetic. HvBterical attuekii am Hlighter iii degree^ not 
at'wimpanied with alhuminuria, antl cv)ii.sc'iou«ne:*« is not m- 
firt'li/ lost. Apoplrrtir oned are rare^ and are followed hv eom- 
jdete cinim and |Miralysi^i, ilue to effiwion, or a cloi of Mood 
within the eranimn. The ttffii/'al pneri>eral eonvulsiou is epl- 
hpiir. in charucler. It l>e^iu8 with rolling of the eyelmll, 
puckering of the lips, drawing of the lower jaw on one side, 
UendiitL^ the head hack or toward one Hboulder. Then follow 
twktchiu;: of the facial mui^'K'g and of tho^ of the cxtremi* 
tiew ; pnitnision of the tonjrue ; i^rindinjr of the twth ; violent 
jerkin^r i»f the urnis ; in fact, clonic H|HLsm of the vofrnttary 
miwcte.-*, and some of the /»* voluntary ont^ notably thoj^e of 
respiration ; hence lividity of the li|jt* and face, ili«tende<J 
veins in the neck, and apparent impending cyanosis. At Hrst, 
liowever, the respiration ia burrie<l anfl irrejrnlnr, bif<Hing, 
through Ulmxly fnHli. lx;lween the teeth. Urine an4l fe<*«e 
S(mtetime3 involuntarily discharged. Duration of the con- 
vulsiou from one to four minute*. Con»plete uiiouusciousneaa 
iluring |>aroxy*m. the [>atient having afterward no recollec- 
tion of it. The mi^ may re^'ur at varying intervals, of miuutee 
or hours, and in varying uuml>er. from two or three to twenty, 
thirty, or more. They are apt to recur with the recurrence 
of a lalH)r-paiu. They sometimes come on uftrr labor with* 
out having occurred before il. The uterus may jtiirticijtate 
in the ^pusjuu and exjiel the child rapidly — an unusual recur- 
ren<«, not to ha autici|Miled or waite<l for. 

ProfjnoitiA. — Always seriou.s to lH)th mother and ehilil, in- 
cre4wing in gravity with the f*everity of the .symptoms and 
exinting im|»edimentfl to speedy delivery- The ctmvnlsiona 
n)ay }>er»ist even after labor. Fortunately, they do not ix'-our 
more than once in four or Hve huntlred labors. 

Trenirnenf of VonvnlaiouM tfurimj hdtor, — If {)i>80ible ascer- 
tain the cause. A historv of unemia attenda most cases, the 




522 PUERPIcnAl ECLAMPSIA DVRrXO LASOB. 

treuttiieiit for whieh (inirpitiveft, (Huplutretics, rertain diuretics, 
and methods of reducing renal oimj^fHtiou) lut* Iteeti nireaily 
coiisidereil (C'lmpler VIII.). Should tlii» treatiut^nt m4 have 
b€ien pre>'ious!y employed, purjration may Htill In- of i>ei»eftt, 
A drop of iTutoii oil. or a i'ourtli of a praiti oi' tdateriu, nmy 
be ]jlace<l on the baok of the tongue if the wonnm I* coina- 
toee ; or, if hIio can swallow, calomel and jaliip nuiy l»e jjiven 
by the mouth, or a ooucentrale<l siolutioii of E|iHom salt, 
re|>ejUt>d every 15 or M) minutes. 

Tlie relief of uotiviilj^iidif. meanwhile, chiefly elainw our 
attention. Duriutf the paroxy.sm, prevent the patient from 
self-injury, and ]>la(!e a |>ieee of wimhI, or a .s[>oon-hnndle 
wrap|>e<l in Hunnel. or a folded napkin between the teeth, to 
protK't the ton^nie from being bitten. 

During eoma. JoUounnrf the convulsion, the tongue sotue- 
tiineB fulls bitcku'ord, closing the glottis an<l threatening suflb- 
cation. Pull it forward wilh a tenaculum, or volsella forceps. 
When the fit is over the remeilies are : in dic'uMhj itU'thorlc 
women, bleeding from the iirm. It re^luees cerebral w>nges- 
lion and vawular fulnctfti — condition.H indicated by a strong, 
full, lK>unding puli*e and lividity of the face — and may pre- 
vent a fatal ai>oplexy. 

Arter blading, or when it is not »dvi«ible, inject fnrge doees 
of morphia ( j grain) hy|MMlernialicaliy, and repeat as oAen as 
the convulsions recur : ;w much a» li or 4 grains may be ^ven 
in 24 hours. 

In place of the mor]>hia. chloral hydrate in large doeee — 30 
grains — every three hourM. nuiy Ite given, tir twice this ijuautity 
by the rectum, if the patient cannot swallow. 

Aniu«the?ia with chhrofonn may be rewrted to on tlie 
apprt»nrh of returning paroxysnis. 

The fluid extract of veratrum viride in large dtweB (10- 
20 minims), given hyjHHUnnimUy, has Ijeen successful in (con- 
trolling the ecmvulnions ; the s|uisms ceai^e to recur when the 
pulse is reduce*! to 60 per minute. One large do«e (as altove) 
is first given. This, op a smaller ilose, may l>e re|>eated in 
thirty niinute**, if nnpiireil. When the pulse-rate has been 
rt*duce<i to 61), smaller di>ses nf o minims nmy iie <y)atinued, 
at longer intervals, to keep it so. The veratrum viride and 
morphia may l>e iriven fotjftht'r hyi^^dermically, often with 
excellent results. In various hospitals mnvulsiuiiB have beea 





TREATMENT OF CONVULSIONS DVRINQ LABOR, 523 

trpat<*<l ex|«'nnient«lly on niorpliiti u!oii*; on cfiloral ttinue, and 
mi chloroiWnii tt/onr. The In^t reMjlt? were utituiiied From Ibe 
niorphin tri-iUrju-ut. Tlio la-xi U'st was clilonil. 

As a gfiitriil rule, it ts uilvisulik- U) <lt4ivt*r liy fnrct'iw a^ 
stH>n nii (lilaliUioii of the 00 uteri will )H'rruit ; hut this is nut 
by any nR'aiiy uhvavB rfquired. Shoulil the coiiviilflions have 
lieen f-dtiiritujtly fuiitmlled by other reniwlieM. luhor may jro ou 
and he Irt't to complete iti^elf, any violent eHorts with fi>rfeps 
heinji^ liaUlc lo provoke a rf|K.'titiou of the eehuiifitit' paroxysm. 
It* the t'oriviilHiou^ eoutinue in spile of treulinetil, delivery 
otfers' tlie uiily [H)rl of nafeiy. Then, if the <w he nut sntH- 
ciently dilated for f()ree|is to he aj)piie<l, it may l)e either in- 
cised or diluti'd with IJarneaV hai;K, or by tlie fingers — the 
former perhaps lieing, on the whole, preferable — though 
neither proceeding is universally eommeude<i, the other alter- 
native of vereiou by the feet being someLimes neleeteil in- 
stejid. Version, however, ought not to be attempted uidess 
the eonditiouji favorable for its easy |ierfbrmaiu'e are present. 
Anything like violent or i^rolonged manipulation during it« 
performance would be alriit>st sure to increase the eonvulsioiis. 
(hi the whole, nn^t unlhurilie^ consider version decidedly iti- 
atlvi^alde, the eouditioiiH lor il>* easy iK-rformance l)eing seldom 
present. Whatever method of delivery l>e attempted, com- 
plete unsei^thesia slKni]<i he induced during the operation. 

5[uch will de|iend u|)on the parlicuhir circumstances of 
each cai*e and the judgment and skill of ilu.' o|»eralor. When 
circumstances render both forceps and version diffieult and 
inadvisalde, aud the symptoms increase in severity in such a 
degree as to threaten the woman*b life unless the delivery 
sooti tiike place, crnoiotoniy may be required. Such cases are 
verj* exceptiouuh 

In a few casc^ C'iesarean s^-^'tion has bepi» (hme, not only to 
save the (dnld, but alst.> in the interest of the motlier. The 
rej»ulls, while not altogether unfavorable, have not yet l)een 
sutticiently conclusive to warrant a deeide<l opiniou as to the 
advisability of the n[>eration. 

It is sftmelinies advantageous to ru|)lure the meinbranea 
early, even before dilatation of the «>s, the pains afterward 
iMM'oming more efficient, iiiul tin- Itndi'ncy to convulsions 
diniinisheil, owing |»erhn[is to consecpjcnl reduction in the size 
and weight of the uterus and in its pressure upon hloodvesBels, 



524 



PUERPERAL SEPTICEMIA. 



The hot, wet jmck and vft|K»r Imth <iiti he used to advan- 
toge» fv**!! (hiring hilior. niul williout inU*rt'erinfr witli it^ pn»g- 
reSB, retuiiiCHi urinary cxrreta bein;; thus eliniiimle*! with the 
piH>fiwo iHTSpimtiitn tlmt t^nsuoji, or an oiilire hot Imlh rimy Ix* 
euipluyetl. iw rwoiiiiiieiKled id Chiiptor V'lII. (l^jre 145> ; oue 
or the other .should he uswl in every ctme, the eliiniuation of 
urea hy the wkiu l>einfr of extvemr iin|M)rtaii('e. The use of 
pilortirpitie, in <l(w;^ of Iroui one-tiixth li» one-thini of n jrruin 
every two hours, given hy hy]K)deriiiir injection, to proiluce 
ftwentiii^'. htiH l»eei» hitddy reconuutnuK-il, Imt it is rii>t 80 sale 
fls the hot liHlli, and is iillej^cd to pnMiutr piilnuuuiry ii^ieiiia. 
It has l)ren rereiilly rondemned aa the u'ltrst of all reme<li«« 
used ; and this hy the hi^jhtst authority. 

In pueqwral convuLsiuiis itot of iinernic origin, diligent 
intiuiry inunt lie made for otlier causes, and their removal 
attempted. Di.-^lrnlion of the hladder and riH^'tuin. or a 
stoinnch overloa'it'd with intlitre^1ihle food, may lie at the nx>t 
of the dJHorder. Treatineut aceordingly. 

Uystt'ri<-al rouvuLsiouh rwpiinf valerian and other antisfias- 
nio*Iirs. Ameniic i)alients niny need al<.'oholie stinudanta, and 
aUerwani in»n, food, and hitter lonitv. 

Durinir third sla>;e of lulwr the placenta must be delivered 
without delay ; eloti* removed, and firm uterine rontraction 
secured. Then, i)erfecl rest in a dark room. c<fhl to the head, 
laxative eneniata, attention to the bhoMcr, ndlk diet, and, if 
eonvuLsions s;ill coniiMue, morphia rjr rldoral as Itefore. iSult- 
sequent renal disease may, exee)>tioually, require treatment. 



CHAPTER XXXIV 



PUERPKUAI, SKITICKMrA. 



PrF.RPF.RALSKi'Ti<*.i^:Mi.v ( «A/rr Rvnonyms : ehihil>ed fever; 
lyinir-iii fever; pner|>*'ral fever, etc.; imnirrn synonyma: 
puer|>end wpsis ; puer|>eral inicctiim. ete. ) is a fever Iteji^ia- 
oiiig within a wet-k after labor — usually from the ihml (o the 



PUERPEHAL SEP'nrJCMhi. 



526 



fifth flay, inclusive — attoiuie*! wilb iepiic ivff^rlum of the blood, 
auil with aciiit' infiammntiott of oim.' tir iiinre of tlie refiroduHive 
onjaa^ (vulva, viij^iiiu, uteruN Fiillo|iiuii lul>t«, ovaries) or 
their annexii' (cellular tb<!iue and |>oriionouni ), or of Ujth. 
Other or^'iLiiif not helonjfiug to (be rtpRMluc-live eyutcui, via., 
the UlaiMer, ureters, ami kidneys; or, airaiii, the other istToug 
nipinhran4\s — pleura, |M'ricariliuui. am! tlw synovial mc» of 
jniiiti* — may he Jtvc/tnt'irihj iullainetl also. Still, again, from 
the tlimtin^ away ^md hidi^'enient of infecle*! einholi iu remote 
organs, there may oecur serious lesions of the hejirt, lung*s 
and other iiii|Mjrtant structurc-s. The A«vi/ U^tions are, there- 
fore, extrenu'ly iiunutrous ami eomi)lii'ateiJ. Nor is the kind 
of ldi>od-|ioL'ioninjj: always the same ; s-aprieinia, |iya,'mia, se|> 
lii'u'nua, ouo or all, may occur, uloucor conjointly, in the aame 
patient. 

With thisLfreat nund>erand variety of alinormal [jhonomeua, 
liH-al and p^neral, and their t-'ingled ndations with each other, 
the [iiuholo^y of the disease is difficult to understand. The 
ditfereiii atteniptA thus far made to divide and cInsHity the 
various It^ions into definite groups are none uf them faultletw, 
and some have resulte<l in pro<luciDg a complex nomenclature 
that is very confusing'. 

The chief division of caseti is made l>y separatifip those due 
to infection throuu'h the hjmpfintics i'nmi ihoi-e due to infe<'lion 
through the iUmlvtwel*, As miuht, n priori, l>e supposed, the 
two kinds of infection often coexist. 

In hftnphttiie ijiftrium, inoculation taketi place tlirou^h lym- 
phatic vessels, ojwned hy wounds, of the genital canal, whence 
the streptococci make their way into tlu! tissues, producing 
metritis. |>prilt»nilis, cellulitis, am! various other local inHatn- 
mations. The fyiiiphatii's the?nseives art* etdar^red and in- 
tlanied i lyiiiphanjLdlis) ; and eventually the microbes reach 
the hliHtd, and ftwalled " /i/i«/>/m/iV septicxniia " results, la 
vtmcuhr inffctlott^ incHMiIalion takes place ihrou^h the blood- 
vessels and blood, (►ftcii bejfinninp in ehds (fhrundii) formed io 
the mouths of vessels at the [dacental site. The thrombi 
break up and Hoat away to form eml>oli iu distant orjLfuna, 
which bec^)me inHamctl, with consequent metastatic ahsc4^seiC8 
and pyaemia. The veins thorn**elvtrs are enlnrgei.1 and inflamed 
(phlebitis), and eventually the iiife<'linif niirrobes produce 
geueral blood-poidouing, so-c^iUed " trnua-s eepticseniia." 



526 



PUERPERAL SEPTICEMIA. 



A third form of septic infection (sapneniia) ari^efl from ab- 
sorption of ptonmVus due to puirefyinj: timterials in the utenis, 
witliont liny eutrunce of niicnilM* by eilher the lymiilmtics or 
bloodvt'HPt'is. 

All three coiiditioua, viz.. lymphatic i^piicuniia, venous 
Heplicji iiiia, iind Kifmrmia, tnay cr>exit*t \n the wjiiie {latierit. 
It i^ uliuoht inijHMSfible to iK>)ute the sevcrul forms of iiife«"tion 
by diagnf>?ti<' »yni]»toma, and, if we could, the main principles 
of treatment would still be the &anie. 

At prej*ent the eutire Bubjei't is bristling with unsettled 
questions and iheuriw. the iuvarinble (Minsecpu-nee of imper- 
fect knowledj^'e. With niort* li^hl in the l»lun% Hmplicity 
will doubtU^is pupplniit the present confusion. 

There are, however, certain hmdinjLr j'ncU, eai^ily uuderstnixi 
and forming ibt' tinindation of our current knowledge of this 
di&eaH^, the couiprebensiun of which will lead uh (o intelligojit 
metbotls of preveniiou and cure. These will now be preaented. 

Causkb and Orkiin. — Given ten Kinp-in women* whose 
lalxtre may have been nonnal or abnormal, short or loiijr, 
simple or coiuplicaled, Jjre of them make a pood "gettinp 
up" and roi'itver without a dud ^vm|itiim ; the itihrr fire arv 
attacked wiili chilly lever, hii^di icniperatiire. profound general 
depret^ion, and other pyniftlonis nt" lilnod-|»oisoitintr, together 
with inHainmaiinn, ulceration, sup])uratioM, slougliing, al^&cesa, 
gangreue, or what not, of one or more of the reproductive 
orgaup (as l»efore metitioned ), while pome of tliem die. What 
make£ this ivnnruw difffrntrf in the two e*»tK of cases l* Himply 
tbat tUefir/^t w*t, in which no bad symptoms o^'curred, eacaped 
septic infwtion, while the atcoml fet vrre infef'te<l (really in- 
oculated) with w^ptir nmterial containing pathogenic germs or 
micndn*. (There may be case's — of pure wipnemia, for ex- 
ample, hereafter eonsidered — which ih;^ *»tateuienl will not 
cover ; it, neverihelcsp, embrnees the great nuijority of casea, 
and is the leading fact in our conception of the pathology and 
treatment of this di3ejii*e. ) The septic matter, with its paih<v 
genie germs or micnd>es. goins entrnucr into the woman's 
lK»«ly (into her blood or lymphatic vci?«els) through nouiKfit, 
the wounded surfaces, inevitaldy pre*ient in all labor cases, 
resulting from fore rat iLtug of the genital Imrt — <»f the vulva, 
perineum, cervix uteri, etc. — together with the larger Rurfsce 



CAUSES AND ORtGIK 



527 



from which the pUirenta liiis separate*!. In some lal»or 
the lacerations inenttone<l are small, tiu|M!riic'ial, atxl insig- 
nificant; in others deeper and more extensive, ami while the 
latter incre-ase the danirer, the fmofUitt xvouml (like the soratch 
of a pin or the pnni-ture of a lancet, as in vaa-ination ) may 
be amply gntfirient to admit pathogenic micro-orpanisniH whoi»e 
rapi*! propagation, af>er admisfiion, may l>e just as (lisajilroua 
as if the woiuul had l»een larj^'er. 

What lire these micT(M)rgani:*ni8? We shall never see them 
at the l>edsi(le, ami the part played in diKuu* hy the ditfereut 
varietieti uf microlies is still a matter of iuvestigatiou hy l)ao- 
teriologists. There are^ however, two kimh of organism that 
coneern us in piHT|>eral fever, I hat act dilfereatly, ami whose 
action helps to explain the ilifferenoea olieerved in different 
caaes of the diaease. These are (1) bacfrria and (2) atrepto- 
cocci (The student is presumerl to know that bactrnu are 
rod-shajM^d Ixviii*, calh^l alno hacilli, Baprophvtea, etc., and 
that jttrfpfororci are a variety of mirfococci (dot-t»hu|>e<i bodies) 
in which the single fwints of several micrococci np|x'ur united 
in rftnins or wreatliH. ) In »ome ca^^eti etaphylocorri and other 
microl>e8 may be found. But let tis leave these out for the 
present and fX)nHider bttrierin and strf^pfooot^i and their action. 
Bacteria are agenla of putrefaction ; without them putrefaction 
cttimot occur ; they attack ihad tiattne**, such jw l>itfl of placenta, 
roemhranes, blootl-clots, etc. ; during putrefaction, ptoinatm 
are produce*! ; these ptontaina are altsw^rhe*! into the b!ood 
and [x>i8on the [mtient, either mildly or fatally, according to 
circumstances. This form of blood-poisoning is variously 
called '*8apra;mia," **putrid intoxication," or "septic intoxi- 
cation," and, since Imcteria produce it, bacteria are oaUed 
** pntref active tjemui.** 

Streptococci are agents of infection: they attack living 
tissues, produce inflammation and its various lesions and local 
death of iwrtd in which they are greatly multiplied. Tissues 
that have thus been invaded, and we might say "killed." by 
the streptococci^ ttmv become a suitable soil for badcrin, with 
consequent putrefaction and ptomain-poisoning. Thus the 
two species of microbes are often found together. The strep- 
tocotri, having once gained entrance to a freshly woundei! sur- 
face, make their way — chietiy through lymph veeaels and 
bloodvessels, but also through the Quest lymph spaces b^ 



528 



VUKRrERAL SEPTICEMIA. 




tween the tueue elemeiite — to (liferent parls of tlie body. 

Thua the various loml inflnmmatiotis result i'roru imp*>rtatwitM 
of utreplocwri — hL firft a ftimill cotimiunity of niicrobe^ thai 
800U niulliplies into nn iuvaiiing anity which ilet^truyi* the 
tissues, and then oonie l)a('teria to <Hgtil ptuiiiaYitd from the 
**dea<i" left by the destroyer. Thus the streptowx'ci (and 
their allies) are '* injevtivr' genus;'* the bacteria are '* putre- 
fariive germs." 

From the action of these two 8et« of microbee all the uumer- 
oua local leeiouB (inflanimalory proceeses), ami ea<'h of the 
several phases of ^uernl bIuud-|K)iHoniiig atteuding this diHeaiset 
may, in one way or other, l>e aocouule<l for aat.1 eiplaiited. 

It is unfortunate that recent texl-hookfi c<mtain terms '( based 
upon the different action of thene two sets of gernw) that »re 
extremely confusing. Thus, we are asked to separate ^'general 
putrui infection" from ••general efpfic infection;" and to 
remember that "putrid endometritis" is one thing and 
'* aejHic endometritis " another. Yet the very derivation of 
the word septic is from the Greek m^-w, to putrefy. Again, 
general pntn'fi iidViiou in called "sapnemia," and general 
septic infe^•tion m callnl *' ^eptirttitiia." In 9o-«ille<I '* putrid" 
cases, Imcteria and their residting ptomains are the active 
agenta of disease; in the so-called ** septic*^ cast* t?treptococci 
are the factors of diseaiM?. 

Where do the miiTo-orfpmisms come from^ and how do thtt/ 
obtain accets to the iroviann iroundnf They come from with- 
out, and are intro<luced on the handK. instruments, and ap- 
{)aratus of physicians and nursee : on svringes, catheten 
specula, sponges, cloths, napkins, bed-pans, etc Anything, 
whether solid, liqni<i. or gaseous Tas air), containing theee 
germs, that comes in contact with the genitnl {uissage aod its 
wounded surfaces, may Iea<i to infection. 

Since modern antiseptic midwifery has caused the hands, 
instruments, and materials used in the lying-in room to be 
sterilizwl — rendere<l aseptic — free from germs, this disease 
has l>een almost blotted out of existence even in maternity 
huspitals, where it UBe<l to he both frer|uent and fatal. But 
it still o^vurs, in private as well as in hospital practice, occa- 
sionally, either fmm faulty or neglected antiseptic manage* 
ment, or from unknown and unexpected sources of contagion 
that have oooaequently escaped detection and sterilization. 



CAUSES AND ORJQIS. 



529 



The disease may be coiiveye*! from an iiife<*Ut(l woman to a 
lu'allhy one. PulieuUf with eryBi|n'hLS, diphtheria, farhiincle, 
and gtippuruting wouikU are known to produce the patho- 
gonif gemiB that in lying-in women lead to puerperal fever. 
Henoe no obetetrioiaii or nurse fihouhl go from these ca&es to 
atr<Mid a lal>or ciuie, t'hyi*i<MunH have tlieniselves lK*en known 
li> iiiKct MOTiien, by Irnviug at the time of their attendance, 
in their own [>erson.s a niueo-puruleut coryaa, a suppurative 
udfrdtie, and the reiiiaina of a dis»e**tinfr wound. I'hysinana 
who di.s.sc< 1 or tnako autojteiea are liable to carry itdtHrtion, at 
lenat from sejitic [xjdies, to their puer|ienil patienta. 

The air w sometimes the source of infection. It may he 
conrjiniitiat4Hl with microbes from other puer()eral fever pft- 
tientis ; streptococci have been found in fioattog air dusL 
Air may be rendered infective by sewer )a:ns, by burst.e<l waste- 
pi|>i's, \\\ the "contiguity of churchyards, dung-hills, privies, 
staldeft, slaughter houses, cesspools," and many other pta<*es 
where the decomposition of organic matter is going on. A 
dead animal, even a rut or mouse in the waiuRxit, may cause 
a ihvelling to swarm with infecting germs. 

Most oAen the dei-ompoeing nmterial in whidi the germs 
nmltiply is found in the uterine cavity itself, especially in 
pieces of retainei] placenta, faUal or detadual mendtranes, 
hl(K)dH*lots. etc. Retention and decom]x»sition of the KK'hia 
may nl»> connliiute a nidus for the development and riiuhipli- 
t-ation of microbes. It is interesting to remend)er that the 
normal Ifn'hial discharge ci^ntains an abundance of fnffortftes, 
which, it is well-kiu^wn, feed U|X)n and destroy uiicrobes (the 
process of " phagocytosis" ) ; and in some t-ases of puer])eral 
endometritis the uiicrosc^ipists have found just underneath 
the more 3U[»ertii.ial layer of necrotic tissue in the uterine 
cavity a (so-called) "granulation " layer, mcamiiiig unth leu- 
cfinjti'H, which acts as a protet'tion arul defence against the in- 
vasion of |Mithngenir germs. Tht^ result of this conilict largely 
depends ujKMi luirnbers ; the K'ueocytes may successively co|»e 
with a limited niindter rtf nucndies and protect the woman 
fi-om a fatal result, but should tliis lindted niim1>er be multi- 
plied ten niillinn times the le.icoc>*tea are over|x>wered. and 
unlc?«* nature's little army of white bhKxI-corpuwIes l>e re- 
inforced by the more sweeping gernncides supplied by the 
ulwtctriciau's antise|iitics, a fatal result will uflcu ensue. 
•4 



530 




PVERPF.RAL SEPTICEMIA. 



Symptoms ani> Pathoi.o«y. — These nre mutually <te- 

{ indent mid insejaruMe. The frreat nuinWr and variety of 
ooal k-sionSt the tVeiiiieut fnexii*tenoe of j*ever!il in (he same 
patient, and the varyitijij; kiiidn and degree}* ol' hlmxl-noisoning 
a'lider the s_vnqit<Hns and juitholojry extremely coaiplienle<L 
In |iriieti<'e it may Ik? im|M>p*iihIe by any sort ot* examination 
to tell e.xnvffij the preeiHL' lesion i*r Wions exifltinjLr in a given 
wise. TluT*' nre, however, eertniti hroud iliHtinctiona, de|»en<l- 
inp mainly U|>on tlie orL^ans or strurtures afteeted, that are 
cnHily recojridzeti, ami the reeoguilion of which in of jiraetical 
ijsi^ ill outlining' trealnifut S>nie of the attempted more finely 
drawn distinctionr* i^re of little use. tor, in many inetamrts. 
u(l:er the most lalK»re<i refiuements of iliugnoBiB, treatment re- 
niainn tlie same. 

Two nfiA of syt!»ptoms require to he note<l. viz. : (1) Sifmf>- 
ioms of bfood-pomndug, and {2j sf/rnpionM and sigm of htflav^ 
mntion and 'u& results. 



1. Symptoms op Bi.oon-poisoNiuo. — These vary in degree 
— in intensity — in different raises ; may Iw alip'ht or pprj- 
nouDced. The most imj»re»«ive and Iiesr define*! clinical pic- 
ttire of these symjitorns is pr««^nte<l in eafies oi* t^rptinmiin 
arttfijfAima (acutest aepticremia, eoK-nlleil In' Onrrigru**). and 
in which the nervous system is so overwhelmed by the in- 
tensity of the hlootl-poison as to cause death within a few 
days. 8ynip[on)8 nre: chill, pnjlonijed and violent; head- 
ache; fever ; tenifierature rises t^) \0A° F. or hiirher, hut «x)n 
declines to j*"6norinaI. In doing so it must neeivwjirily pojw 
the normal j»i>int, hence^ straneely, a temjwjrary norma/ Irm- 
pa-aiurr nmy U* present. The most uolalde and ominous 
symptom is |iorha|)H the ertrrwe tjeiteml depremon, indicated 
hy Jrequmnj iimX fephhnrHs t>f pnW, the rate beinp I'JO, 140. 
or even U>0 per minute. Rapid respiration. Delirium, g^>ing 
on (o stufior aiifl coma. Anxious expression, sometimes with 
dusky or purplish color of the skin, and pinche*! features. 
Bowels lihwe. with thin. dark, offensive eva<'uations, that be- 
come involuntary. Tonj^'ue thickly coate*! ; nt fin^t yellowish, 
fsmnx l>eeomin;j brinvn and dry. Sphn-n tender and enlarge*!. 
Urine s(*anty and loade<t with albumin. There nmy be no 
Bwpllinf:^ or |>ain in the alulomen. The lochia may 1m* dimin- 
iahe<i or supprcsswi ; sometimes horribly offensive; oecasionaliy 




VULVITIS AND VAOINITTS. 



531 



without o<lor. The uterus not well contrnt't^], but «>fl, Hahhy, 
ftml larjr<% willi the im and cervix |mtiihtufl ciiutitjli tn nisily 
ailiiiit a Hitj^er, The Hviniitoiii^ liegin Boon aHer lal)or, aud 
liiiith usually otrurs witliiu tweuty-tbur or ibrty-t-ii^ht hours. 

Few cawv of thiy iutt-usity o<rur iiowiiday.'^. They were 
common euovigh years ngn^ es|K.H'inlly (luring the en<leini<« in 
lying-in hospitals*, hofore the use of nntiaeptios, when the fatal- 
ities re«embie(] those (►f plague, cholera, aud other njalignaut 
diseanee. 

Note, once for all, that theee symptoniis in if'*'* pronttuuced 
degree*^ will l>e pre^jent in every cAse of puerperal infection. 
EH|KH'ially to Ik; nwte<l is i\w. frcijueiiey aud Jwhienetui of jnilee, 
indicating general deprea^ion, which is often out of prof¥>rtion 
to tho other eymploms. Nervous SMnpionis — rejitlessnwe, de- 
lirium, Bomnolencc, stupor, etc. — are always of liad omen. 

2, Symptoms axd Sioks of Tjocal Inflammation. — 
These, with their ree|>eclive ingeparable j)atbological tissue- 
changes, will Ik! here arranged. a(!<*t>rding to the organs and 
tissues iii(ianie<l. in the Ibllowing order: Vulvitis, vacinitis, 
nieiriris, HJilpingilitu, ovariiis, cellulitis, |)elvic peritonitis, ab- 
iloniinal jHTitoniti:«, i^erimrditis, pleuritu», pneuuiouitis, phle- 
bitis, lymphangitis, etc. 

Vulvitis and Vaginitis. — Symptoms are: redness, pain 
ftenderneflB and wnarting when urine pa«>ea over inflamed 
surface*), heat, swelling (sometimes (rdemn of vulva), and a 
mupo-piirulent diwharge, just aj» in any other catarrhal inflam- 
mation. Retention of urine from (i\\(»llen meatua or urethra. 
The 3U(>erfitiid (cntjirrhal) inHnmnuition may proceeil to 
ulv.t'nition and ahitceni^^ or ttfouijliintj and tjiin(jrt'nt\ ut onee 
recognized hy ins])ectinn of the parts. One form of the dis- 
ease de^ierves 8[K*riul nM^ognition. viz.. diphiherilic vulrititf and 
»vi//r»iVM. Here the ulcerations (and lacerations, if there be 
any ) are coverol with a gray or grayish-yellow exudation 
( r«»i'iid>ling the |iatclii»» obser\'ed ujKiu the throat and ton- 
sils in diphtheria) an<l are ac^'ompanied with swelling and 
temlenioiiH <if the inguinal gInudH. The lochia are otfensive 
aud nniy he suppre»tfH»d. The grncraf symptoms will de- 
pend on the kind aud degree of blood-poisoning, already 
considered. 



632 



rUEnPERAL SEPTJCEMIA. 



M1CTRITI8 (Inflammation of the Uterus). — SymptomB: 
Pain m ami teiiikTiifA-t on inanipulatinn of the uterus, which 
in foutxl ti> he eiilar<^''e(l uml hoHer ihuii norinul ; ufler-pains 
very ]tniiiftil ; Um-Iuu tiftunlly fetid and more hloody than 
normal. Ou vacinal examination, ns and cervix utx»ri are 
hot, swollen, and tender to the t<jnch. Various other ^yin|>- 
lonis (Hrur dcperidin*: n|)on the progress of the inriammatory 
process. The su|)ertieial (ratarrhal) intlamnmtioD (endome- 
tritis) may |»rocoe<I deeper until ulceration and filoufrliiujf 
occur, will) oflensive diK-harge coutjiining pus and dtbrio of 
broketHlown uterine ti^j^ue ; sometime** a whole slab or slice 
of muHculnr tinsue sioiitrlia off and is diw'hargcd (calleti " di»- 
Becting meiritift " ) with an ahnndanee of pus. The ca*e may 
also i»e<v)me iHphth^nHf, with tfray, «*anty. and fetid lochia, 
au<l the npptnirantre of diplilherilic patches ufKin the cervij:, 
eeeu by examination throu^'h fiiK'cnlnni. The paiu may ex- 
tend from the uterus down the lower linihe. Chill and fever 
are not very pronounced. A moderate rise of leni|ierHture at 
first is folhmed by a daily increase as tlie caw* procwMls from 
bail to wonM?. fi^^wels uHuntlv (^jnsti|»ated. l)ut there is little 
or no alwlominal distention. The pMieral symptoms of bI(X>d- 
poi(*rtnin^ will, of «mr»c, he more pronounced in diphtheritic 
case? and in those where the iutiantmaliou had extended deeply 
into the uterine walls. 



Salpingitis (Tvfi.ammation of FAi.i.oriAN Ti^be) and 
Ovaritis f Inflammation of the Ovary). — S^inptomfl 
usually follow or attend metritis, inflammation extending 
from uterus to tuhi« and ovarit*. While there may he acute 
lancinating pain in the atfeotcti tube or ovary, these diseases 
are so often an<l intimately associated with metritis and lociil- 
ized peritonitis that it is almost ini]>o»!ible to isolate them 
during the pnerjwrium. There is usually great tenderueai 
over the inllametl organs, and their enlargement can be 
detected as a tangible ma«* high up in the vagina! fornix. 
usually on one t^ide or nlK>ve and l>ehind the cervix, nith the 
finger, on bimanual examination. 

CELLUi-rriB (pARAMi-rrRms). — An inflammation of tlie 

pelvic i*ellular or connective tiRsuc, belwcen the uterus* and 

ff peritoneum, e